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The effect of pharmacist-provided non-dispensing services on patient outcomes, health service utilisation and costs in low- and middle-income countries

  1. Sami Pande1,*,
  2. Janet E Hiller2,
  3. Nancy Nkansah3,
  4. Lisa Bero4

Editorial Group: Cochrane Effective Practice and Organisation of Care Group

Published Online: 28 FEB 2013

Assessed as up-to-date: 1 SEP 2012

DOI: 10.1002/14651858.CD010398


How to Cite

Pande S, Hiller JE, Nkansah N, Bero L. The effect of pharmacist-provided non-dispensing services on patient outcomes, health service utilisation and costs in low- and middle-income countries. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD010398. DOI: 10.1002/14651858.CD010398.

Author Information

  1. 1

    The University of Adelaide, Adelaide, Australia

  2. 2

    Australian Catholic University, Faculty of Health Sciences, Fitzroy, VICTORIA, Australia

  3. 3

    University of California, San Francisco, Clinical Pharmacy, Fresno, California, USA

  4. 4

    University of California San Francisco, Department of Clinical Pharmacy and Institute for Health Policy Studies, San Francisco, California, USA

*Sami Pande, The University of Adelaide, Adelaide, Australia. samipande@gmail.com.

Publication History

  1. Publication Status: New
  2. Published Online: 28 FEB 2013

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

 
Summary of findings for the main comparison.

1(c) Comparison of the delivery of patient targeted services by pharmacists versus usual care

Patient or population:

Pharmacies  or pharmacists delivering services in outpatient settings and patients with various diseases*

Settings: Chile (2), Thailand (2) , Bulgaria (2), India (2), Sudan (1), Egypt(1) and Paraguay (1)

Intervention: Counselling/Patient Education (3), Counselling/Patient Education + Booklet (4), Counselling + Drug Review (1), Pharmaceutical plan with scheduled follow-up + Patient education + Booklet (4),  Counselling +  Booklet + Special medical container (1), Counselling + Special medical container (1)

Comparison: Usual care provided by pharmacists

OutcomesImpactNo of Participants
(studies)
Quality of the evidence
(GRADE)

Clinical outcomes

(fasting blood glucose,random blood glucose, glycosylated haemoglobin, systolic blood pressure, blood cholesterol, peak expiratory flow rate; follow-up: 16 to 24 weeks)

(Abdelhamid 2008; Adepu 2007; Arun 2008; Ebid 2006; Gonzalez-Martin 2003; Lugo 2007; Paulos 2005; Petkova 2008; Sookaneknun 2004; Suppapitiporn 2005; Zwarenstein 2007)
Small improvements in outcomes1791

(10)
⊕⊕⊝⊝

low1

Quality of life

(measured with asthma specific assessment form, brief pain inventory for arthritis, paediatric asthma quality of life questionnaire, SF-36, diabetes dependent quality of life questionnaire, health related quality of life for asthma/COPD; follow-up 9 to 24 weeks)

(Abdelhamid 2008; Arun 2008; Ebid 2006; Gonzalez-Martin 2003; Paulos 2005; Petkova 2008; Petkova 2009)
Small improvements in quality of life777

(7)
⊕⊕⊕⊝

moderate2

Health service utilisation

(rate of hospitalisation, emergency room visits, general practitioner visits; follow-up: 18 to 20 weeks)

(Abdelhamid 2008, Ebid 2006; Petkova 2008; Petkova 2009)
Decreased health service utilisation590

(4)
⊕⊕⊝⊝

low1

Cost

(follow-up: 6 months)

(Ebid 2006)
Reduction in cost

 
350

(1)
⊕⊕⊝⊝

low3

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1. The quality of evidence was downgraded to 'low' because of study limitations (risk of bias) in most of the studies and due to the inconsistencies (heterogeneous outcome)
2. The quality of evidence was downgraded to 'moderate' due to the inconsistencies (heterogeneous outcome)
3. The quality of evidence was downgraded to 'low' because of the inclusion of a single study and imprecision round the estimate of effect .
 

 Summary of findings 2

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

Over the past two decades the role of pharmacists has expanded beyond medication dispensing (for example giving medicines to patients), packaging (for example counting and putting pills in a bottle to be given to patients) and compounding (WHO 1998). Pharmacists are increasingly considered as a part of the healthcare system whether in community pharmacies, primary health centres or hospitals (Ghani 2010; WHO 1998).

In light of factors such as socio-economic status; lifestyle; accessibility; management of acute, chronic and recurrent illness; public health and environmental factors; health sector reforms; availability of new products; and demographic and epidemiological factors there is a trend towards self-medication and self-care (WHO 1998). Pharmacists can play an important role in self-medication and self-care by providing and interpreting information regarding appropriate health care and medication choices and they promote the rational use of drugs. Furthermore, increased health demand, an increasingly complex range of medicine uses, and poor adherence to prescribed medication have provided additional opportunities for pharmacists to deliver patient targeted services (WHO 2006). The concept of “the seven star pharmacists” was developed by a WHO consultative group, which states that the well-rounded pharmacist should be a compassionate caregiver, decision-maker, active communicator, lifelong learner and good manager, and should possess the qualities of a good leader, teacher and researcher (WHO 1997). According to Hepler and Strand 1990, pharmacists are responsible for providing ‘pharmaceutical care’ to improve patients' quality of life; this involves a) identifying potential and actual drug-related problems, b) resolving actual drug-related problems, and c) preventing potential drug-related problems (Hepler 1990). Recently, the concept of medication therapy management (MTM) has been used to further describe collaborative methods to achieve optimal patient outcomes and promote safe and effective medicine use (APAaNAoCDS 2008). MTM services are focused on patient centred care rather than product centred care and are targeted to prevent medication-related morbidity and mortality. They can be considered as an activity when pharmacists (including but not limited to hospital and community pharmacists) are reimbursed for reviewing patients’ medications and advising them and their carers about necessary changes but without dispensing. MTM services include a medication regimen review, the provision of personal medication records, the construct of a medication-related action plan (which may include therapeutic recommendations, a provider referral), documentation and follow-up as needed. 

Various patient targeted services, which may be either drug or health-related, are performed by pharmacists. Pharmacists can compile and maintain information on a patient’s drug history, assist physicians in the rational prescribing of drugs, ensure a patient's understanding of the dosing regimen and method of administration, and help in improving patient adherence (Lipton 1994; WHO 1994). In addition, they may collect and maintain information on all medicines, particularly newly introduced medicines, and provide advice to all healthcare professionals, as necessary (Lipton 1992; WHO 1994). From a public health standpoint, pharmacists may be actively involved in health promotion campaigns like tobacco control; moderate alcohol use; nutrition and healthy lifestyle; routine immunization; management and prevention of infectious diseases such as HIV/AIDS, tuberculosis and diarrhoea; and in the management of mental health and other chronic diseases (Aderemi-Williams 2007; Rosen 1978; WHO 1994).

Contrary to the situation in high income countries, pharmacists are underutilised for patient care in low- and middle-income countries; and the importance of their role as healthcare professionals in hospitals, community pharmacies and healthcare teams has not been well recognized (Anderson 2002). Moreover, although the World Health Organization (WHO) is trying to promote Good Pharmacy Practice (GPP) in all countries, pharmacy practice in low- and middle-income countries is very poor as compared to that in high income countries (Ghani 2010, Smith 2009). GPP is the national standard set for “the promotion of health, the supply of medicines, medical devices, patient self-care, and improving prescribing and medicine use by pharmacists’ activities” (FIP 1997). Major barriers for effective pharmacy practice in low- and middle-income countries include an acute shortage of qualified pharmacists, the preference of pharmacists to work in urban areas rather than rural areas, failure to implement the separation of dispensing practices between doctors’ clinics and pharmacies, especially in countries where the pharmacists are not the sole dispenser and doctors are allowed to dispense as well, weak regulatory enforcement of drug sales, irrational use of medicines, reliance on untrained health workers for delivery of services, and general  poverty (Fabricant 1987; Geest 1987; WHO 1994). Furthermore a focus on profits, which is characteristic of certain dispensing practices, rather than the provision of optimal health care promotes irrational use and prescribing of drugs; this issue may not be unique to low- and middle-income countries. The marketing strategies (the push) of pharmaceutical companies to promote sales combined with the demand for (the pull) or the desirability of modern medicines and their role in preventing diseases are also causes of the irrational use of drugs (Fabricant 1987; Geest 1987; le Grand 1999; WHO 1994). In addition, cultural norms such as the prestige of physicians and the prevalence of polypharmacy, including combining traditional medicines with allopathic medicines, contribute to the irrational use of drugs. The public health consequences of this kind of haphazard drug utilisation result in lethal effects due to inappropriate self-medication (for example underdosing or overdosing, inappropriate medication selection), antibiotic resistance due to overusage as well as undertherapeutic-dosage usage, drug dependence due to the use of tranquillizers and painkillers, and high risk of infection due to the improper usage of injections (Geest 1982; Kamat 1998; le Grand 1999). With  the serious and widespread public health problem of the irrational use of medicines (Holloway 2006) and the need to improve health outcomes, it is necessary to examine the impact of pharmacists' clinical patient care interventions in addition to standard dispensing and compounding in low- and middle-income countries (WHO 2009).

 

Why it is important to do this review

Previous systematic reviews have focused on high and low- and middle-income countries, specific settings such as ambulatory care, acute care and long-term care, and specific patient groups (Beney 2000; Blenkinsopp 2003; Christensen 2006; Horn 2006; Kaboli 2006; Kane 2003; Nkansah 2010; Royal 2006; Singhal 1999; Tully 2000). None of these reviews have evaluated the effects of pharmacist interventions on patient outcomes, health service utilisation and costs by focusing solely on low- and middle-income countries.

The protocol for this review was based on the Cochrane review entitled “Expanding the roles of outpatient pharmacists: effects on health service utilization, costs, and patient outcomes” published in 2000, which included eligible studies published from 1966 to 1999 (Beney 2000) and the updated version of that review, which included studies published up until 2008 (Nkansah 2010). However, the updated review (Nkansah 2010) included only randomised controlled trials whereas the original review (Beney 2000) included a broad range of study designs such as controlled before and after studies, non-randomised controlled trials and interrupted time series analyses. Few studies (Gonzalez-Martin 2003; Paulos 2005; Sookaneknun 2004) included in the reviews (Beney 2000; Nkansah 2010) were from low- and middle-income countries and the applicability of the findings of those reviews to low- and middle-income countries are uncertain. Our review includes a broad range of study designs such as randomised controlled trials, controlled before and after studies, non-randomised controlled trials and interrupted time series analyses.This review, differs from the other two reviews (Beney 2000; Nkansah 2010) by (i) focusing solely on low- and middle-income countries, according to the World Bank’s country classification (World Bank Group 2009), and (ii) by searching for studies with a variety of designs that were published up until January 2010 that met the inclusion criteria.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

The aim of this systematic review was to evaluate the effect of pharmacist-provided non-dispensing services on patient outcomes, health service utilisation and costs in low- and middle-income countries.

 The following main research questions were examined.

1. In low- and middle-income countries, what are the effects of the delivery of patient targeted services by pharmacists on patient outcomes, the use of health services and costs compared to:

a. delivery of the same services by other healthcare professionals?

b. delivery of the same services by untrained health workers?

c. usual care?

2. In low- and middle-income countries, what are the effects of the delivery of healthcare professional targeted services by pharmacists on patient outcomes, the use of health services and costs compared to:

a. delivery of the same services by other healthcare professionals?

b. delivery of the same services by untrained health workers?

c. usual care?

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms
 

Criteria for considering studies for this review

 

Types of studies

All studies that met the following inclusion criteria were included in this review.

1. Randomised controlled trials (RCT) randomising either patients or pharmacists or practices (pharmacies) or geographical areas

2. Non-randomised controlled trials (NRCT)

3. Controlled before-after studies (CBA) (with at least two intervention sites and two control sites)

4.  Interrupted time series analyses (ITS) (with clearly defined dates and at least three data points before as well as after the intervention)

 

Types of participants

The participants included in this review were pharmacists (or pharmacies) delivering services in outpatient settings other than or in addition to drug compounding and dispensing. Studies analysing services to patients in hospitals or nursing homes were excluded. Studies of pharmacists delivering services to an outpatient pharmacy attached to a clinic or hospital, community pharmacies or primary health centres were included in the review. In studies that were randomised by pharmacy or geographical area, the pharmacy services could have been delivered by pharmacists or pharmacy technicians. Therefore, the profession of the individuals who actually delivered the pharmacy services was determined. The research sites or pharmacies must had been located in low or middle income countries at the time of the study regardless of the location or the origin of the researchers. The low- and middle-income countries were selected according to the World Bank’s country classification (World Bank Group 2009).

 

Types of interventions

All pharmacist-provided non-dispensing services were considered as an intervention. However, there is no agreed upon terminology that defines pharmacist-provided non-dispensing services, and various terms have been used interchangeably to refer to the same services for example non-distributive or non-dispensing services. In this review, this term refers to drug-related patient targeted services delivered by pharmacists other than drug compounding and dispensing. Other services not related to pharmaceutical products, such as the selling of cosmetics, were excluded. To be included, educational or counselling sessions had to be extended or patients had to be continuously followed-up compared to the one to two minute basic counselling typically offered. The content of each intervention including recipients, format, source, timing, setting, and cost were noted, when available.

 

Types of outcome measures

Our outcomes of interest included patient outcomes (clinical outcomes, quality of life) and healthcare process outcomes such as health service utilisation (rate of hospitalisation and number of general physician visits) and costs. Subjective outcomes such as self-reporting of symptom or satisfaction level were not included in this review. Studies were included only if they reported objective measurement of an outcome. If the study measured only subjective outcomes, it was excluded. We did not include adverse effects as we did not anticipate that any studies would measure them.

 

Search methods for identification of studies

Studies were identified by electronically searching the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2010), MEDLINE (1949 to September 2010), Scopus (1960 to 2010) and International Pharmaceutical Abstracts (1970 to January 2010). An update of this review is currently ongoing. The search was re-run September 2012 and the potentially relevant studies are awaiting classification (Characteristics of studies awaiting classification). In MEDLINE, a  broad search was conducted by using the MeSH headings ‘pharmacy’, ‘pharmacist’ and various publication types such as ‘randomised controlled trial’, ‘controlled clinical trial’ along with synonyms for ‘low or middle-income countries’ and names of low- and middle-income countries according to the World Bank’s list (World Bank Group 2009). The search strategies were modified according to the database indicated in Appendix 2. In addition, the reference lists of all eligible studies were checked.

 

Data collection and analysis

 

Selection of studies

Two review authors independently selected the trials to be included in the review. Disagreements were resolved by discussion of the articles by at least two of the authors of the review. Two phases of study selection were performed. Firstly, only titles and abstracts were assessed for inclusion. In the next phase, the full texts of potentially eligible studies were reviewed thoroughly. Only studies excluded in the second phase were presented in the Characteristics of excluded studies, with the reason for exclusion. In the case of ambiguity, further information was sought from the authors to make a decision about eligibility. References were managed using Endnote X3.

 

Data extraction and management

Data from the eligible studies were independently extracted by two authors using an electronic data extraction checklist. The included studies are presented in the Characteristics of included studies table. Studies that were excluded are presented in the Characteristics of excluded studies table with the reasons for exclusion.

 

Assessment of risk of bias in included studies

Risk of bias was assessed independently by two authors using the Cochrane Effective Practice and Organisation of Care (EPOC) data extraction checklist for each included study design. The discrepancies were adjudicated by discussion of the studies.

1. Randomised controlled trials (RCTs) and controlled trials without random allocation (quasi-RCTs): sequence generation; concealment of allocation (protection against selection bias); similar baseline outcome measurements, similar baseline characteristics, blinded assessment of outcome(s) (protection against detection bias); incomplete outcome data adequately addressed, protection against contamination, free from selective outcome reporting and free from other risks of bias.

2. Interrupted time series analyses (ITS): intervention independent of other changes, shape of the intervention effect pre-specified, intervention unlikely to affect data collection, knowledge of the allocated interventions adequately prevented during the study, incomplete outcome data adequately addressed, study free from selective outcome reporting and study free from other risks of bias.

3. Controlled before and after studies (CBA): sequence generation; concealment of allocation (protection against selection bias); baseline outcome measurement similar, baseline characteristics similar, blinded assessment of primary outcome(s) (protection against detection bias); incomplete outcome data adequately addressed, protection against contamination; free from selective outcome reporting and free from other risks of bias.

The risk of bias for outcomes was summarized either as low risk of bias, high risk of bias or unclear risk of bias for each individual study.  For included studies, the risk of bias characteristics are described in the Characteristics of included studies table.

 

Measures of treatment effect

Results for baseline (pre-intervention) and end-of-study (post-intervention) periods were reported, if available, in the Data and analyses tables. Where possible, pre-post intervention differences for each outcome for the control and intervention groups and the difference in the pre-post intervention change between study groups were calculated. For each outcome, statistical significance was provided in the significance column and, if available, whether the results were statistically significant were reported. The outcomes reported in each study are listed in the Characteristics of included studies table and the results for each outcome are reported in the Data and analyses tables.

 

Assessment of heterogeneity

As variations in outcomes and interventions were anticipated, the results were not statistically combined.

 

Sensitivity analysis

No sensitivity analysis was conducted as quantitative synthesis of results was not anticipated.

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification.

The full texts of 77 studies were retrieved (Figure 1). Of these, two studies were multiple reports and 63 studies did not meet the review inclusion criteria. Twelve studies were included. All of these were randomised controlled trials (RCT). Of the 12 studies, seven were from lower middle income countries and five were from upper middle income countries. Details of the included studies are presented in the Characteristics of included studies table.

 FigureFigure 1. Prisma flow chart.

 

Characteristics of the interventions

Of the 12 included studies, 11 examined pharmacist interventions targeted at patients (Abdelhamid 2008; Adepu 2007; Arun 2008; Ebid 2006; Gonzalez-Martin 2003; Lugo 2007; Paulos 2005; Petkova 2008; Petkova 2009; Sookaneknun 2004; Suppapitiporn 2005) and one study evaluated a pharmacist intervention targeted at healthcare professionals (Zwarenstein 2007).

All studies involved comparisons between pharmacist-provided non-dispensing services and usual care. Comparisons of pharmacist-provided services targeted at patients versus services delivered by other healthcare professionals or untrained healthcare workers were not found. Similarly, comparisons of pharmacist-provided services targeted at healthcare professionals versus services delivered by other healthcare professionals or untrained healthcare workers were not found. Eleven of 12 studies were randomised by patient and one study was cluster randomised by general practice.

In 11 studies targeted at patients, the main aim of the pharmacist intervention was patient education and counselling (Abdelhamid 2008; Adepu 2007; Arun 2008; Ebid 2006; Gonzalez-Martin 2003; Paulos 2005; Petkova 2008; Petkova 2009; Lugo 2007; Sookaneknun 2004; Suppapitiporn 2005). The main content of educational sessions and counselling included information about the mechanism of disease and associated risk factors, pharmacotherapy (dosage, duration, route of administration, possible adverse effects of medications and training on using medication devices) and non-pharmacological measures of controlling disease including lifestyle, diet modifications and self-management. Four of 11 studies involved complete pharmaceutical care follow-up by providing patient education; pharmaceutical therapy optimisation; monitoring of disease control; compliance assessment; identifying and resolving drug-related problems; and maintaining manual records for each patient by recording personal data such as drug therapy, adherence to treatment, lifestyle, drug-related problems and other clinical variables such as blood pressure and level of triglycerides (Ebid 2006; Lugo 2007; Paulos 2005; Sookaneknun 2004). Specifically designed educational booklets explaining the disease, medication and lifestyle modifications were also provided to patients in seven of 11 studies (Adepu 2007; Ebid 2006; Lugo 2007; Paulos 2005; Petkova 2008; Sookaneknun 2004; Suppapitiporn 2005). Counselling using a booklet and a special medication container were also provided to the patients in one study (Suppapitiporn 2005). Details are in  Table 1.

Four of 11 studies were conducted in the outpatient departments of hospitals (Abdelhamid 2008; Ebid 2006; Gonzalez-Martin 2003; Suppapitiporn 2005), five studies took place in a community pharmacy (Adepu 2007; Lugo 2007; Paulos 2005; Petkova 2008; Petkova 2009), one study was conducted in primary health centres (Arun 2008; Sookaneknun 2004) and one study took place in both a primary health centre and community pharmacy (Sookaneknun 2004). The duration of the intervention ranged from 20 to 50 minutes with three to 11 interventions conducted over a period of nine weeks to six months.

One of 12 studies targeted healthcare professionals. In this study, pharmacists provided educational sessions to general practitioners (GPs) which contained eight key messages aimed at improving diagnosis, prescribing and follow-up care for children with asthma. The intervention was academic detailing and tools such as visual aids were used ( Table 2). Educational sessions were conducted in general practices. The duration of the intervention was 30 minutes and two interventions were conducted over 12 weeks (Zwarenstein 2007).

The control group received usual care in each of the 12 studies. Usual care entailed traditional care provided by pharmacies or primary healthcare units without comprehensive pharmaceutical care and follow-up or patient education or counselling. However, in one of the studies the control group received the intervention at the end of the study ( Adepu 2007). In one study there was one control group and four intervention groups (Suppapitiporn 2005). In this study, diabetic drug counselling was provided by a pharmacist to all intervention groups; one group had an additional diabetes booklet, another had special medication containers and the third group was provided with diabetes education, a diabetes booklet and special medication containers.

 

Characteristics of providers delivering the intervention

In all studies, the interventions were performed either by practicing pharmacists or research pharmacists. In four studies, a single pharmacist provided the intervention (Abdelhamid 2008; Paulos 2005; Sookaneknun 2004, Suppapitiporn 2005; Zwarenstein 2007). However, the number of pharmacists was not clear in most of the studies (Adepu 2007; Arun 2008; Ebid 2006; Gonzalez-Martin 2003; Lugo 2007). In two studies the intervention was delivered by both a pharmacist and pharmacy students who had passed an examination in pharmaceutical care (Petkova 2008; Petkova 2009).

 

Target population

All 11 studies targeted patients based on their disease state. Three targeted patients with asthma (Abdelhamid 2008; Gonzalez-Martin 2003; Petkova 2008), three selected patients suffering from type-2 diabetes mellitus (Adepu 2007; Arun 2008; Suppapitiporn 2005) and one targeted patients with asthma or chronic obstructive pulmonary disease (COPD) (Ebid 2006). Lugo 2007; Paulos 2005; Petkova 2009 and Sookaneknun 2004 selected patients with hypertension, dyslipidemia, rheumatoid arthritis or osteoarthritis and hypertension respectively.

In a study examining pharmacist interventions with GPs, participants were selected based on their location, in Mitchells Plain, Cape Town South Africa (Zwarenstein 2007). The main aim of the study was to improve diagnosis, prescribing and follow-up care provided by GPs for children with asthma.

The number of participants ranged from 21 to 360 patients and 43 general practices. One patient targeted study included pediatric patients and another study targeted participants aged 14 years and over. The other studies targeted adults aged 18 years and over.

 

Characteristics of countries

Single studies were conducted in Sudan, Egypt, Paraguay and South Africa (Characteristics of included studies). In addition, two studies were conducted in each of Chile, Thailand, Bulgaria and India. Of the 12 studies, seven were from lower middle income countries and five were from upper middle income countries. Eligible studies conducted in low income countries were not identified (Characteristics of excluded studies).

 

Risk of bias in included studies

The analysis of the risk of bias present in the included studies is presented in the Risk of bias in included studies table under each study in the section presenting the Characteristics of included studies. A graphical representation of risk of bias is given in Figure 2 and Figure 3.

 FigureFigure 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
 FigureFigure 3. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Eleven of the 12 studies in this review had a risk of bias. Only three of 12 studies had an adequately generated sequence for randomisation (Petkova 2008; Petkova 2009; Zwarenstein 2007). Ten of 12 studies did not explicitly describe whether allocation concealment was done (Adepu 2007; Arun 2008; Ebid 2006; Gonzalez-Martin 2003,Lugo 2007; Paulos 2005; Petkova 2008; Petkova 2009; Sookaneknun 2004; Suppapitiporn 2005) and in one study an on-site computer system was used for the allocation concealment (Zwarenstein 2007). Baseline measurements of outcomes were comparable in only four of 12 studies (Abdelhamid 2008; Arun 2008; Gonzalez-Martin 2003; Petkova 2008), however it was unclear in the other four studies (Adepu 2007; Ebid 2006; Lugo 2007; Paulos 2005). Baseline characteristics were similar between the intervention group and control group in seven of 12 studies (Adepu 2007; Arun 2008; Ebid 2006; Gonzalez-Martin 2003; Sookaneknun 2004; Suppapitiporn 2005; Zwarenstein 2007), however it was unclear in the other two studies (Abdelhamid 2008; Paulos 2005). Furthermore, there was high risk of bias for the protection against contamination in nine studies (Abdelhamid 2008; Adepu 2007; Arun 2008; Ebid 2006; Gonzalez-Martin 2003; Paulos 2005; Petkova 2008; Petkova 2009; Suppapitiporn 2005) and unclear in two studies (Lugo 2007; Sookaneknun 2004). As only objective outcomes were included in this review, all studies were coded as having blinded assessment of outcomes. There was high risk of bias in assessment of outcome data in two of 12 studies (Abdelhamid 2008; Ebid 2006), unclear in two studies (Arun 2008; Paulos 2005) and at low risk of bias in the rest of the studies. The absence of selective reporting of results could not be assessed in Gonzalez-Martin 2003, Paulos 2005 and Suppapitiporn 2005 as the outcomes to be measured was not listed in the methods sections of the studies. Other forms of bias were not identified in all 12 studies.

 

Effects of interventions

See:  Summary of findings for the main comparison;  Summary of findings 2

All included outcomes are listed in the Characteristics of included studies table and the Data and analyses tables.

No studies were identified that met the criteria for comparison of the delivery of patient targeted services by: (a) pharmacists versus other healthcare professionals, and (b) pharmacists versus untrained health workers.

 

Comparison of the delivery of patient targeted services by pharmacists versus usual care

Eleven of 12 studies that compared the effect of pharmacist interventions targeted at patients versus usual care were included in this review. Detailed descriptions are presented in  Analysis 1.1.

 
Clinical outcomes

All studies targeting patients reported patient outcomes. Patient targeted pharmacist interventions resulted in improvement in most of the clinical outcomes, although the improvement was not always statistically significant. The peak expiratory flow rate increased by 1.76 l/min in the intervention group as compared to the control group in one study (Abdelhamid 2008) however the result was not statistically significant. The effect size of the improvement of peak expiratory flow rate was not reported in the other study although the result was statistically significant (Petkova 2008). In patients with asthma, a statistically significant difference was not found in forced vital capacity (FVC) and forced expiratory flow (FEV) from spirometry testing before and after the intervention (Gonzalez-Martin 2003). Two studies demonstrated a reduction in systolic and diastolic blood pressure (Lugo 2007; Sookaneknun 2004). Reduction in systolic and diastolic blood pressure due to pharmacist intervention (Lugo 2007; Sookaneknun 2004) was -25 mm Hg and -6 mm Hg and -4.56 mm Hg and -2.45 mm Hg, respectively. However, in one study, reporting of standard deviations was incomplete (Lugo 2007). Two studies targeting diabetic patients showed a statistically significant reduction in the fasting plasma glucose level (Arun 2008; Suppapitiporn 2005) and one study showed a statistically significant reduction in the random blood glucose level (Adepu 2007). The reduction in fasting plasma glucose levels due to pharmacist interventions (Arun 2008; Suppapitiporn 2005) was -39.84 mg/dl and -16.16 mg/dl, respectively. In patients with diabetes, the glycosylated haemoglobin level decreased by -1.04% in the intervention group as compared to the control group (Suppapitiporn 2005). When each intervention versus control was analysed in this study, the mean percentage point difference between the intervention and control groups ranged from -0.75% to -1.23 %. In one study, the total cholesterol level and triglyceride level of the dyslipidemic patients decreased by -25.7 mg/dl and -80.1 mg/dl in the intervention group as compared to the control group, respectively (Paulos 2005). In the same study, there was an increase in the proportion of patients with decreased cholesterol.

Overall, pharmacist-provided services targeted towards the patient point to small improvements in some of the clinical outcomes such as management of high glucose levels among diabetic patients and management of blood-pressure and cholesterol levels. For outcomes such as peak expiratory flow rate and forced vital capacity, we could not rule out the role of chance in these findings.

 
Quality of life outcomes

Seven of 11 studies reporting patient outcomes collected data on quality of life outcomes (QOL) by using various QOL questionnaires (Adepu 2007; Arun 2008; Ebid 2006; Gonzalez-Martin 2003; Paulos 2005; Petkova 2008; Petkova 2009). One study targeted at diabetic patients showed a statistically significant improvement in QOL; however numerical data for this effect were not reported (Adepu 2007). A second study targeting diabetic patients reported an increment in QOL score by 5.45 (score range 0 to 30) in the intervention group, but it was not clear whether this result was statistically significant (Arun 2008). In Gonzalez-Martin 2003, there was an increment of the emotion, activities and symptom score (on a scale range from 1 to 7 for each item) by 1.3, 2.1 and 1.7, respectively, in the intervention group as compared to control group. The mean difference of the QOL score assessed by using an asthma specific assessment form (score range 1 to 5) was 0.61 between the intervention and control groups in Petkova 2008. Small but statistically significant improvements in QOL were reported in a study targeting arthritic patients (Petkova 2009). A study targeting dyslipidemic patients also showed a statistically significant improvement in QOL (Paulos 2005), however the effect size was not reported. Lastly, another study targeting patients with asthma and COPD demonstrated a statistically significant increment in QOL score in the intervention group, but the difference between the intervention and control groups was not reported (Ebid 2006). Due to the poor reporting, the overall effect size of improvement in QOL by the pharmacist intervention could not be estimated as the included studies used different measures of QOL or reported different outcomes. However, most of the studies showed a statistically significant improvement in QOL score.

In summary, the measurement of QOL in the seven studies varied greatly but suggests that pharmacist interventions targeting patients may improve the QOL outcomes.

 
Process outcomes (health service utilisation and cost)

Four of 11 studies targeting patients reported process outcomes (Abdelhamid 2008; Ebid 2006; Petkova 2008; Petkova 2009). In two studies, the rate of hospitalisation decreased statistically significantly in the intervention groups as compared to the control groups (Abdelhamid 2008; Petkova 2008). Effect sizes for health service utilisation were not reported in two studies (Abdelhamid 2008; Ebid 2006). The hospitalisation rate of asthmatic patients decreased by 15.7%; the 'need for visits to general practitioners (GP) less than two to three times' parameter increased by 19.2% and the 'need for visits to GPs greater than six times' parameter decreased by 4.6% (Petkova 2008). In arthritic patients, the 'no need of visit to GP' parameter increased by 16.3% and the 'need of visit to GP for more than six times' parameter decreased by 14% (Petkova 2009). Similarly, in another study the number of visits to private clinics (PCs) or outpatients clinics (OPCs) and emergency rooms of hospitals decreased in the intervention group in both asthmatic patients and patients suffering from COPD (Ebid 2006). Specific effect sizes were not reported. In the same study, medication costs for patients with COPD and asthma were also decreased.

Overall, pharmacist-provided services were able to reduce health service utilisations such as GP visits and hospitalisation rate.

 

Comparison between interventions

The pharmacist interventions targeting patients were counselling and patient education; counselling with patient education plus an educational booklet; counselling and drug review; a pharmaceutical care plan with scheduled follow-up; counselling, booklet and special medication container; and counselling and special medication container ( Table 1). For the blood glucose outcome, counselling and 'counselling plus a booklet plus medication container' were the most effective interventions as compared to other interventions such as 'counselling plus medication container' or 'counselling plus a booklet' (Suppapitiporn 2005). A pharmaceutical care plan with scheduled follow-up also showed an effective result (Arun 2008) for this outcome. For blood pressure, a pharmaceutical care plan with scheduled follow-up was more effective in Lugo 2007 as compared to Sookaneknun 2004. A pharmaceutical care plan also showed an effective result for the improvement of blood triglyceride and cholesterol levels (Paulos 2005). 'Counselling and booklet' (Petkova 2008) was more effective in improving peak expiratory flow rate as compared to 'counselling and drug review' (Abdelhamid 2008) among asthmatic patients. The effect of 'counselling plus a booklet' on arthritic patients was small but significant (Petkova 2009). The rate of hospitalisation decreased by 19.2% and GP visits decreased by 15.7% among asthmatic patients when assessing 'counselling and a booklet' (Petkova 2008). Similarly, 'counselling and a booklet' was assessed in Petkova 2009 and increased the 'no need to visit to GP' parameter by 16.3% and 'the need to visit a GP for more than six times' parameter by 14%. The single study assessing the effect of the pharmacist intervention on medication costs assessed an intervention of a pharmaceutical care plan with scheduled follow-up (Ebid 2006). The pharmaceutical care significantly reduced the medication costs in Ebid 2006. Most of the studies did not report effect sizes, hence it was not possible to compare the pharmacist interventions. Overall, counselling plus a booklet and a pharmaceutical care plan with scheduled follow-up were the most effective interventions.

 

Comparison 2(c): comparison of the delivery of healthcare professional targeted services by pharmacists versus usual care

One study that compared the effectiveness of a pharmacist intervention targeted at healthcare professionals versus usual care was included in this review (Zwarenstein 2007). A single pharmacist delivered outreach visits in this study and the improvement in the asthma symptom score due to the intervention was 0.85 with a P value of 0.03 (with little or no difference in symptoms at the lower end of the CI). A detailed description is presented in  Analysis 1.1.

 

Quality of the evidence (GRADE analysis)

A Grade analysis was done to determine the quality of the evidence for the clinical outcomes, quality of life, health service utilisation and cost for comparisons 1(c) and 2(c) ( Summary of findings for the main comparison;  Summary of findings 2). There was a small improvement in clinical outcomes with the patient targeted pharmacist-provided services as compared to usual care and the quality of the evidence was graded low. There were small improvements in the quality of life scores and the quality of evidence was graded low. The health service utilisation was also decreased for this comparison and the quality of evidence was graded low. Medication cost was also decreased by the pharmacist interventions and the quality of evidence was low. The study that targeted healthcare professionals comparing pharmacist provided services to usual care showed that the intervention decreased the asthma symptom score, however the quality of evidence was graded low.

 

Assessment of heterogeneity

The three studies that demonstrated little impact had small sample sizes (21 to 90), which may explain the lack of statistical significance (Gonzalez-Martin 2003; Petkova 2008; Petkova 2009). Five of 11 studies did not present data supporting statements about the outcomes thus making it difficult to estimate the magnitude of effect (Abdelhamid 2008; Adepu 2007; Arun 2008; Ebid 2006; Paulos 2005). We tried to contact the authors, but none of them responded. Only a single study discussed the clinical importance of the intervention effect on the outcome (Zwarenstein 2007). Among the eligible studies, there was great heterogeneity in comparison groups, intervention type, outcomes assessed, duration of intervention, length of follow-up and the measurement used for outcomes. An attempt was made to perform a meta-analysis by subgrouping studies based on the disease state and outcome type. Unfortunately, there were insufficient data across the 12 included trials to perform subgroup analyses for any disease state. For example, in the two studies assessing disease control in adult asthmatic patients, studies used different quality of life questionnaires (Abdelhamid 2008; Petkova 2008). Due to the different outcome measures and measurement units, pooling data from these outcomes was not possible. As single studies assessed outcomes for hyperlipidemia, chronic obstructive pulmonary disease (COPD) and arthritis, meta-analysis was not possible. Although three studies (Adepu 2007; Arun 2008; Suppapitiporn 2005) assessed the effectiveness of the interventions on blood glucose, only one study (Suppapitiporn 2005) reported the pre-intervention and post-intervention value of the outcome and its standard deviation. Hence, meta-analysis could not be performed. For similar reasons it was not possible to perform a meta-analysis for blood pressure-related outcomes. Consequently, data were presented separately for each included study.

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms
 

Summary of main results

This review has demonstrated that pharmacist interventions targeting patients may improve patient outcomes and health service utilisation in middle income countries. Pharmacist interventions targeting patients resulted in a small improvement of clinical outcomes. A small Improvement in quality of life was demonstrated in most of the studies although some studies did not report a measure of effect. Although few studies assessed process outcomes (health service utilisation and cost), health service utilisation such as the rate of hospitalisation and the need for general practitioner visits were also found to be reduced in all of the studies that reported these outcomes. Regarding cost, only medication costs were assessed in a single study and were found to be reduced (Ebid 2006). However, a number of studies did not report this outcome. None of the included studies specifically mentioned the clinical significance or beneficial effect, however clinical significance or beneficial effect can be deduced from the data. 

Only one study examined pharmacist interventions targeting healthcare professionals and it found very small improvements in asthma symptom scores with little or no difference in symptoms at the lower end of the confidence interval. In addition, a single pharmacist delivered outreach visits to healthcare professionals in this study, which might preclude the generalisability of the result due to the pharmacist's personality and personal rapport with practices.

There was heterogeneity noted in the type of pharmacist interventions delivered and the outcome variables measured. However, 'counselling plus a booklet' and a pharmaceutical care plan with scheduled follow-up showed mostly positive outcomes. Interventions differed by site of delivery (for example the outpatient department of hospitals, primary care clinic, community pharmacy), the length of each intervention session (for example 20 minute session with pharmacist, 50 minute session with pharmacist) and the frequency of the intervention (for example 11 sessions per 22 weeks, six sessions over six months).

The most common interventions provided involved simple patient education. Few studies assessed complete pharmaceutical care follow-up, by providing medication therapy optimisation, monitoring of disease control, compliance assessment, identifying and resolving drug-related problems and maintaining manual records for each patient. The terminology used for these services in the studies was ‘pharmaceutical care’, but this is likely to be similar to what is now called 'medication therapy management' (MTM). However, most of the pharmacist interventions targeting patients in other studies conducted in high income countries were complex and comprehensive; these services included MTM consisting of medication optimisation, monitoring of disease control, adverse drug reactions, identification of drug-drug interactions, compliance assessment and patient education (Nkansah 2010). The only included study targeted towards healthcare professionals involved academic detailing and tools such as visual aids for improving diagnosis, prescribing and follow-up. Pharmacist interventions targeting healthcare professionals in high income countries included oral or written recommendations to physicians regarding therapy modifications or resolution of medication-related problems with multiple follow-up visits with patients extending over several months, ranging from one month to 12 months (Nkansah 2010). In the studies conducted in high income countries, the duration of each intervention was longer, ranging from 14 to 120 minutes with one to 22 intervention events conducted over the longer study period that spanned from six weeks to 23 months, compared to low- and middle-income countries. In the studies conducted in low- and middle-income countries, the duration of the intervention ranged from 20 to 50 minutes with three to 11 interventions conducted over a period of nine weeks to six months.

 

Overall completeness and applicability of evidence

Studies which compared the effect of pharmacist-provided non-dispensing services targeted at patients and healthcare professionals with services delivered by other healthcare professionals or untrained workers could not be found. Thus, this review could not assess all of the listed objectives. Only 12 studies which compared pharmacist interventions versus usual care were included in this review. All eligible studies were from middle income countries. Hence, the result of this review is highly applicable to those types of countries. Unfortunately studies conducted in low income countries could not be found. Most of the excluded studies were before and after uncontrolled studies that had few points of measurement before and after the intervention. These studies were also conducted in middle income countries. Thus, there is a need to design and conduct higher quality studies in both low as well as middle income countries. Inclusion of high quality studies from a diverse range of countries would increase the external validity of this comparison.

Eleven of 12 studies included in this review examined pharmacist interventions targeting patients and the remaining one examined the effect on pharmacist interventions targeting healthcare professionals. Only four studies measured health service utilisation; a single study measured medication cost and all 12 studies assessed patient outcomes. Five studies did not report enough data to calculate an effect size for outcomes and instead only provided qualitative statements about results (Abdelhamid 2008; Adepu 2007; Arun 2008; Ebid 2006; Paulos 2005). Some outcomes reported were subjective, however only objective outcomes were included in this study to reduce the risk of bias. Most of the studies enrolled small numbers of participants, that is less than 100 in number (Adepu 2007; Gonzalez-Martin 2003; Paulos 2005; Petkova 2008; Petkova 2009).

As noted above, the findings of this review are applicable to middle income countries. There are various reasons such as lack of resources; variation in the organisation of services, qualifications of pharmacists; and cultural barriers which might preclude the applicability of the results to low income countries. In addition to the pharmacist, there should be sufficient resources such as access to medicines or diagnostic tests in order to successfully implement pharmacist interventions. In addition, the qualifications of pharmacists might vary between low income countries and middle income countries, which can cause the results of pharmacist interventions to differ.

 

Quality of the evidence

A number of studies had some limitations in their methodological quality. Although most studies were blinded, many did not explicitly report methods to conceal allocation of participants to the intervention and control groups. Given the nature of practice-based interventions, it is not always possible to blind patients or pharmacists. The impact of a lack of blinding was likely to be minimal as the outcome variables included in this review were objective (for example blood pressure measurement, validated quality of life questionnaire etc). Although most of the studies described the sequence generation as simple randomisation or computer generation, baseline values of variables other than the primary outcomes were not comparable between the intervention and control groups. This may be a consequence of small sample sizes rather than the method of randomisation. In a few studies, baseline measurement of primary outcomes was not reported. A single study met the protection against contamination criteria (Zwarenstein 2007). This is challenging to accomplish in studies conducted in low resource settings as most studies occur within one clinic setting or one healthcare practice group (with multiple health professionals).

Four studies did not explicitly report clinical importance for patient outcomes such as the blood pressure outcome and blood glucose level outcome or worthwhile effects on health service utilisation of the pharmacist interventions (Abdelhamid 2008; Adepu 2007; Arun 2008; Ebid 2006). Even if there are statistically significant changes in outcomes due to pharmacist interventions, mention of clinical importance or worthwhile effect could help the reader better interpret the implications of study results. Hence, ideally, clinical importance or worthwhile effects should be reported in the studies along with statistical significance for each outcome.

In summary, this review demonstrates that pharmacist interventions targeting patients can improve a number of clinical outcomes and health service utilisation, although the effect size was not always large or statistically significant. In some studies, due to the poor reporting of numerical values, the effect size and statistical significance for outcomes, the results were not interpretable. Meta-analysis, which is performed by pooling data from multiple studies, might have helped in determining the true effect and magnitude of the pharmacist interventions. However, due to limitations in the data reported in studies and heterogeneity in the types of outcomes, clinical conditions and approaches to measurement of outcomes, a meta-analysis could not be performed. Overall, the greatest limitation was the poor reporting of study results, such as no explicit reporting of means and standard deviations along with the exact value of statistical significance, which thus precluded the estimation of the strength of the effect. In addition, limitations in reporting of methodological components such as allocation concealment, sequence generation and follow-up of patients and professionals impacted our ability to thoroughly assess study quality. Therefore, standardised outcome measures for various clinical conditions, proper reporting of outcome data and methodological improvements could help in assessing the impact of pharmacist interventions in low- and middle-income countries.

 

Agreements and disagreements with other studies or reviews

The findings are consistent with the results of other reviews (Beney 2000; Nkansah 2010). All the reviews indicated that pharmacist interventions can lead to improved patient outcomes and health service utilisation for multiple disease states, although effect size may not always be substantial or statistically significant.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

 

Implications for practice

Studies for the comparison of patient targeted services provided by pharmacists versus services provided by other healthcare professionals or untrained healthcare workers were not found. Similarly, studies for the comparison of healthcare professional targeted services provided by pharmacists versus services provided by other healthcare professionals or untrained health care workers were not found. Therefore, conclusions could not be drawn regarding these interventions.

The majority of included studies that compared patient targeted pharmacist intervention versus usual care supported the roles of pharmacists in improving the patient outcomes and health service utilisation as well as delivering patient counselling and care regarding drug therapy and management of their disease condition.

We were uncertain about the beneficial effect of the educational session by pharmacists to healthcare professionals as well as the applicability and generalisability of the findings from this single study. As no study assessed health service utilisation and costs for the comparison, conclusions could not be drawn in this area.

 
Implications for research

High-quality studies to examine the effect of pharmacist-provided non-dispensing services should be conducted in low income countries in addition to middle income countries. Similarly, studies which compare the effect of pharmacist-provided non-dispensing services and services delivered by other healthcare professionals and untrained health workers in developing countries are also required. In addition to simple patient education, medication therapy management consisting of medication optimisation, monitoring of disease control, adverse drug reactions, identification of drug-drug interactions and compliance assessment should also be evaluated in this setting. To guide the reader in interpreting results, clinical significance of the effect or a worthwhile effect should be reported along with numerical data and statistical analyses. Besides assessment of patient outcomes, measurement of process outcomes including health service utilisation and costs should be included as an objective in future studies. To increase the power of studies a larger number of participants should be enrolled so that adequate differences in the effect between intervention and control groups can be detected. Standardisation of reporting of methodological quality, outcome data and measurement of reliable outcomes for various disease states are required to produce valid, reliable and generalisable results. Although the objective of this review was not to assess the impact of pharmacists working in a multi-disciplinary team, there are no such studies that evaluate the effect of the pharmacist working in a multi-disciplinary team versus usual care that have been conducted in these countries. Hence, there is also a need for conducting such type of studies in low- and middle-income countries.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

First and foremost I offer my sincerest gratitude to my supervisor, Professor Janet Hiller, whose supervision, encouragement and support from the preliminary to concluding stages enabled me to successfully complete this review. Moreover, it is my pleasure to thank Professor Lisa Bero, The University of California, San Francisco who suggested the idea for this review and without whom the review would not have been possible. I am also heartily grateful to Dr Nancy Nkansah, The University of California, San Francisco who provided invaluable suggestions and assisted me in accessing required articles.

Besides that, I would also like to thank Maureen Bell, Lucia Zuzolo and Linda Mundy who helped me in successfully running the literature searches. I would also like to give special thanks to librarian Cathy Mahar and The University of South Australia for permitting me to use the library facility. In addition, I would like to offer my appreciation to Mrs Adriana Parrella who helped me in extracting data from the Spanish articles.

Furthermore, I would also like to offer my sincere thanks to Dr Joseph L Mathew, Subish Palaian, Kadir Alam, Ramesh Adepu, Dr David Hughes, Sunantha Osiri, Dr Pornanong Aramwit and Wajira Mahes Palipane who had helped in accessing full texts of the relevant studies.

I am grateful to my friends Shakti Shrestha, Bhuwan KC and Arjun Poudel who helped in searching full texts of the potentially relevant articles.

Lastly, I offer my warm wishes and blessing to my parents and friends who supported me in any respect during the completion of the review.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms
Download statistical data

 
Comparison 1. (c) Comparison of the delivery of patient targeted services by pharmacists versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 OutcomesOther dataNo numeric data

 
Comparison 2. (c) Comparison of the delivery of health care professional-targeted services by pharmacists vs. usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 OutcomeOther dataNo numeric data

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms
 

Appendix 1. Classification of low- and middle-income countries according to the World Bank

Low income economies

Afghanistan 

Guinea-Bisau 

Rwanda 

Bangladesh 

Haiti 

Senegal 

Benin 

Kenya 

Sierra Leone 

Burkina Faso 

Korea, Dem Rep. 

Somalia 

Burundi 

Kyrgyz Republic 

Tajikistan 

Cambodia 

Lao PDR 

Tanzania 

Central African Republic 

Liberia 

Togo 

Chad 

Madagascar 

Uganda 

Comoros 

Malawi 

Uzbekistan 

Congo, Dem. Rep 

Mali 

Vietnam 

Eritrea 

Mauritania 

Yemen, Rep. 

Ethiopia 

Mozambique 

Zambia 

Gambia, The 

Myanmar 

Zimbabwe 

Ghana 

Nepal 

 Guinea 

Niger 

Lower middle income economies

Albania 

Honduras 

Paraguay 

Angola 

India 

Philippines 

Armenia 

Indonesia 

Samoa 

Azerbaijan 

Iran, Islamic Rep. 

São Tomé and Principe 

Belize   

Iraq 

Solomon Islands   

Bhutan 

Jordan 

Sri Lanka 

Bolivia 

Kiribati 

Sudan 

Cameroon 

Kosovo   

Swaziland 

Cape Verde 

Lesotho 

Syrian Arab Republic 

China 

Maldives 

Thailand 

Congo, Rep. 

Marshall Islands 

Timor-Leste 

Côte d'Ivoire 

Micronesia, Fed. Sts. 

Tonga 

Djibouti 

Moldova 

Tunisia 

Ecuador 

Mongolia 

Turkmenistan 

Egypt, Arab Rep. 

Morocco 

Ukraine 

El Salvador 

Nicaragua 

Vanuatu 

Georgia 

Nigeria   

West Bank and Gaza 

Guatemala 

Pakistan   

 Guyana 

Papua New Guinea   

 Upper-middle-income economies

Algeria

American Samoa

Argentina

Belarus

Bosnia and Herzegovina

Botswana

Brazil

Bulgaria

Chile

Columbia

Cost Rica

Cuba

Dominicia

Dominican Republic   

Fiji

Gabon

Grenada

Jamaica

Kazakhstan

Latvia

Lebanon 

Libya 

Lithuania 

Macedonia, FYR  

Malaysia

Mauritius 

Mayotte

Mexico 

Montenegro

Namibia

Palau

Panama 

Peru

Poland 

Romania 

Russian Federation 

Serbia 

Seychelles 

South Africa 

St. Kitts and Nevis 

St. Lucia 

St. Vincent and the Grenadines 

Suriname 

Turkey 

Uruguay

Venezuela, RB 

 

Appendix 2. Search strategy for MEDLINE

1. Pharmacy [mh] OR Pharmacy [tiab] OR pharmacists [mh] OR pharmacists [tiab] OR pharmacist [mh] OR pharmacist [tiab] OR pharmacies [mh] OR pharmacies [tiab] OR community pharmacy [mh] OR community pharmacy [tiab] OR “community pharmacy services” [tiab] OR community pharmacy services [mh] OR community pharmacies [mh] OR community pharmacies [tiab]   OR “pharmaceutical care” [tiab] OR “pharmaceutical cares” [tiab] OR pharmaceutical services [tiab] OR pharmaceutical services [mh] OR pharmaceutical service [tiab]

2. “low- and middle-income countries” [tiab] OR low-and middle-income countries [mh] OR  low- and middle-income nations [mh] OR “low- and middle-income nations” [tiab]  OR developing countries [mh] OR “developing countries” [tiab] OR developing nations[mh] OR “developing nations” [tiab]  OR  “least developed countries” [tiab] OR least developed countries [mh] OR “less developed countries” [tiab] OR less developed countries [mh]  OR less developed nations[mh] OR “less developed nations” [tiab] OR  “least developed nations”[tiab] OR least developed nations [mh] OR “under developed nations” [tiab] OR under developed nations [mh] OR “underdeveloped countries” [tiab] OR under developed countries [mh] OR “poor countries” [tiab] OR poor countries [mh] OR third-world countries [mh] OR “third world countries” [tiab]   OR “third-world nations” [tiab] OR third world nations [mh] OR third world [tiab]

3. Afghanistan [mh] OR Bangladesh [mh] OR Benin [mh] OR Burkina Faso [mh] OR Burundi [mh] OR Cambodia [mh] OR Central African Republic [mh] OR Chad [mh] OR Comoros[mh]  OR Congo [mh] OR Eritrea [mh] OR Ethiopia[mh]  OR Gambia [mh]  OR Ghana[mh]  OR Guinea [mh] OR Guinea-Bissau [mh]  OR Haiti[mh]  OR Kenya[mh]  OR Korea [mh] OR Kyrgyz Republic[mh]  OR Laos [mh] OR Liberia [mh] OR Madagascar [mh] OR Malawi [mh] OR Mali [mh] OR Mauritania [mh] OR Mozambique[mh]  OR Myanmar[mh]  OR Nepal[mh]  OR Niger[mh]  OR Rwanda [mh] OR Senegal[mh]  OR “Sierra Leone” [mh] OR Somalia [mh] OR Tajikistan[mh]  OR Tanzania [mh] OR Togo [mh] OR Uganda [mh] OR Uzbekistan[mh]  OR Vietnam[mh]  OR Yemen [mh] OR Zambia[mh]  OR Zimbabwe [mh] OR Albania [mh] OR Angola [mh] OR Armenia[mh]  OR Azerbaijan [mh] OR Belize [mh] OR Bhutan[mh]  OR Bolivia[mh]  OR Cameroon[mh]  OR Cape Verde [mh] OR China [mh] OR Congo [mh] OR “Cote d'Ivoire” [mh] OR Djibouti [mh] OR Ecuador[mh]  OR Egypt [mh] OR El Salvador [mh] OR Georgia[mh]  OR Guatemala[mh] OR Guyana[mh] OR Honduras [mh] OR India [mh] OR Indonesia[mh] OR Iran [mh]  OR Iraq[mh]  OR Jordan[mh]  OR Kiribati [mh] OR Kosovo [mh] OR Lesotho [mh] OR Maldives [mh] OR Marshall Islands[mh]  OR Micronesia  [mh] OR Moldova [mh] OR Mongolia [mh] OR Morocco [mh] OR Nicaragua [mh] OR Nigeria[mh]  OR Pakistan [mh] OR OR Papua New Guinea OR Paraguay [mh]  OR  Philippines  [mh] OR Samoa [mh] OR Sao Tome and Principe [mh] OR Solomon Island [mh] OR Sri Lanka[mh]  OR Sudan[mh]  OR Syrian Arab Republic [mh] OR Swaziland [mh] OR Thailand [mh] OR Timor-Leste[mh]  OR Tonga [mh] OR Tunisia [mh] OR Turkmenistan [mh] OR Ukraine [mh] OR Vanuatu [mh] OR West Bank and Gaza [mh] OR Algeria[mh]  OR American Samoa[mh]  OR Argentina [mh] OR Belarus [mh] OR Bosnia and Herzegovina [mh] OR “Bosnia-Herzegovina”[mh] OR Botswana [mh] OR Brazil [mh] OR Bulgaria[mh]  OR Chile[mh]  OR Colombia [mh] OR Costa Rica[mh]  OR Cuba [mh] OR Dominica [mh] OR “Dominican Republic” [mh] OR Fiji [mh] OR Gabon [mh] OR Grenada [mh] OR Jamaica [mh] OR Kazakhstan[mh] OR Latvia [mh] OR Lebanon [mh] OR Libya [mh] OR Lithuania[mh]  OR Macedonia [mh]  OR Malaysia[mh]  OR Mauritius [mh] OR Mayotte[mh]  OR Mexico [mh] OR Montenegro[mh]  OR Namibia [mh] OR Palau [mh] OR Panama[mh]  OR Peru[mh]  OR Poland [mh] OR Romania [mh] OR Russian Federation [mh] OR Serbia[mh]  OR Seychelles[mh]  OR South Africa[mh]  OR “St. Kitts and Nevis” [mh]  OR St. Lucia [mh] OR St.Vincent and the Grenadines [mh] OR Suriname [mh] OR Turkey[mh]  OR Uruguay [mh] OR Venezuela  [mh] OR Afghanistan [tiab] OR Bangladesh [tiab] OR Benin [tiab] OR “Burkina Faso” [tiab] OR Burundi [tiab] OR Cambodia [tiab] OR “Central African Republic” [tiab] OR Chad [tiab] OR Comoros[tiab]  OR Congo [tiab] OR Eritrea [tiab] OR Ethiopia[tiab]  OR Gambia [tiab]  OR Ghana[tiab]  OR Guinea [tiab] OR Guinea-Bissau [tiab]  OR Haiti[tiab]  OR Kenya[tiab]  OR Korea [tiab] OR “Kyrgyz Republic”[tiab]  OR “Lao PDR” [tiab] OR laos [tiab] OR Liberia [tiab] OR Madagascar [tiab] OR Malawi [tiab] OR Mali [tiab] OR Mauritania [tiab] OR Mozambique[tiab]  OR Myanmar[tiab]  OR Nepal[tiab]  OR Niger[tiab]  OR Rwanda [tiab] OR Senegal[tiab]  OR “Sierra Leone” [tiab] OR Somalia [tiab] OR Tajikistan[tiab]  OR Tanzania [tiab] OR Togo [tiab] OR Uganda [tiab] OR Uzbekistan[tiab]  OR Vietnam[tiab]  OR Yemen  [tiab] OR Zambia[tiab]  OR Zimbabwe [tiab]  OR Albania [tiab] OR Angola [tiab] OR Armenia[tiab]  OR Azerbaijan [tiab] OR Belize [tiab] OR Bhutan[tiab]  OR Bolivia[tiab]  OR Cameroon[tiab]  OR Cape Verde [tiab] OR China [tiab] OR Congo [tiab] OR “Cote d'Ivoire” [tiab] OR Djibouti [tiab] OR Ecuador[tiab]  OR Egypt [tiab] OR “El Salvador” [tiab] OR Georgia[tiab]  OR Guatemala [tiab] OR Guyana [tiab] OR Honduras [tiab] OR India [tiab] OR Indonesia[tiab] OR Iran [tiab]  OR Iraq[tiab]  OR Jordan[tiab]  OR Kiribati [tiab] OR Kosovo [tiab] OR Lesotho [tiab] OR Maldives [tiab] OR Marshall Islands[tiab]  OR Micronesia [tiab] OR Moldova [tiab] OR Mongolia [tiab] OR Morocco [tiab] OR Nicaragua [tiab] OR Nigeria[tiab]  OR Pakistan [tiab] OR Papua New Guinea[tiab] OR Paraguay [tiab]  OR Philipines  [tiab] OR Samoa [tiab] OR “Sao Tome and Principe” [tiab] OR “Solomon Islands” [tiab] OR Sri Lanka[tiab]  OR Sudan[tiab]  OR “Syrian Arab Republic” [tiab] OR Swaziland [tiab] OR Thailand [tiab] OR Timor-Leste[tiab]  OR Tonga [tiab] OR Tunisia [tiab] OR Turkmenistan [tiab] OR Ukraine [tiab] OR Vanuatu [tiab] OR “West Bank and Gaza” [tiab] OR Algeria[tiab]  OR American Samoa[tiab]  OR Argentina [tiab] OR Belarus [tiab] OR “Bosnia and Herzegovina” [tiab] OR “Bosnia-Herzegovina”[tiab] OR Botswana [tiab] OR Brazil [tiab] OR Bulgaria[tiab]  OR Chile[tiab]  OR Colombia [tiab] OR Costa Rica[tiab]  OR Cuba [tiab] OR Dominica [tiab] OR “Dominican Republic” [tiab] OR Fiji [tiab] OR Gabon [tiab] OR Grenada [tiab] OR Jamaica [tiab] OR Kazakhstan[tiab] OR Latvia [tiab] OR Lebanon [tiab] OR Libya [tiab] OR Lithuania[tiab]  OR Macedonia [tiab]  OR Malaysia[tiab]  OR Mauritius [tiab] OR Mayotte[tiab]  OR Mexico [tiab] OR Montenegro[tiab]  OR Namibia [tiab] OR Palau [tiab] OR Panama[tiab]  OR Peru[tiab]  OR Poland [tiab] OR Romania [tiab] OR Russian Federation [tiab] OR Serbia[tiab]  OR Seychelles[tiab]  OR South Africa[tiab]  OR “St. Kitts and Nevis” [tiab]  St. Lucia [tiab] OR St.Vincent and the Grenadines [tiab] OR Suriname [tiab] OR Turkey[tiab]  OR Uruguay [tiab] OR Venezuela  [tiab]

4. Randomized controlled trial [pt] OR clinical trial [pt] OR random* OR  (pre test OR pretest OR post test OR postest) OR impact OR intervention*  OR evaluat* OR effect* OR compare* OR controlled clinical trial [pt] OR patient education as topic[mh] OR treatment outcome [mh] OR quality of life [mh] OR patient compliance [mh] OR patient compliance [tiab] OR counseling [mh] OR counseling [tiab] OR counselling [tiab] OR counselling [mh] OR patient satisfaction [tiab] OR patient satisfaction [mh] OR random allocation [mh] OR random allocation [tiab] OR Outpatients [tiab] OR  Outpatients [mh] OR  Ambulatory Care [tiab] OR Ambulatory care [mh] OR outpatient clinics[tiab]  [OR] outpatient clinics [mh]

5. (#1 AND (#2 OR 3) AND #4 ) (Limit to Human)

 

Appendix 3. Result table 1(c) Comparison of the delivery of healthcare professional targeted services by pharmacists versus usual care


1(c) Comparison of the delivery of patient targeted services by pharmacists versus usual care

OutcomesImpactNo of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Clinical Outcomes

Fasting Blood Glucose Level (FBG)

(follow-up: mean 5.5 months)

[Intervention: Counselling/Patient Education]
 Mean difference of FBG between intervention and control group ranged from  -16.16 mg/dl  to -39.84 mg/dl

 
514 (2)⊕⊕⊕⊝
moderate
The evidence was downgraded from high to moderate because 'risk of bias' was serious as concealment of allocation; follow-up and reporting regarding outcome were not clear.

Glycosylated Haemoglobin (HbA1c )

(follow-up: 6 months)

[Interventions: Counselling +  Booklet + Special medication container or Counselling + Special medication container or Counselling or Counselling + Booklet]
When each intervention versus control was analysed, the mean percentage point difference between intervention and control ranged from -0.75 mg% to -1.23 mg%360(1)⊕⊕⊕⊕
high
 

Systolic/Diastolic Blood Pressure (SBP/DBP)

(follow-up: mean 6 months)

[Interventions: Pharmaceutical plan with scheduled follow-up + Patient education + Booklet]
Mean difference of SBP between intervention and control group ranged from -4.56 mmHg to -25 mmHg and DBP ranged from -2.45 mmHg to -6 mmHg305(2)⊕⊕⊕⊝
moderate
The evidence was downgraded from high to moderate because 'risk of bias' can be serious as concealment of allocation; follow-up and reporting regarding outcome were not clear.

Blood Cholesterol Level and Triglyceride level

(follow-up: 16 weeks)

[Interventions: Pharmaceutical plan with scheduled follow-up + Patient education + Booklet]
Mean difference of cholesterol level group was -25.7mg/dl and triglyceride level was -80.1 mg/dl between intervention and control

 
42(1)⊕⊕⊕⊝
moderate
The evidence was downgraded from high to moderate because 'risk of bias' can be serious as concealment of allocation; follow-up and reporting regarding outcome were not clear.

Peak Expiratory Flow Rate (PEFR)

(follow-up: mean 20.6 weeks)

[Intreventions: Counselling/Patient Education + Booklet, Counselling + Drug Review and Pharmaceutical plan with scheduled follow-up + Patient education + Booklet]
Mean difference of PEFR was 1.76 l/min. between  intervention and control group*500(3)⊕⊕⊕⊝
moderate
The evidence was downgraded from high to moderate because risk of bias was serious as concealment of allocation was not done in a study and attrition bias was not addressed in two studies.

Random Blood Glucose Level (RBGL)

(follow-up: 6 months)

[Intervention: Counselling/Patient Education + Booklet]
Mean difference of RBGL was -53.71 mg/dl between intervention and control group70(1)⊕⊕⊕⊕
high
 

Quality of Life (QOL) Score

 

Asthma specific assessment form (1- “interference all of the time,” to 5-“interference none of the time”)

(follow-up: 4 months)

[Intervention: Counselling/Patient Education + Booklet]
Mean difference of score between intervention and control group was 0.6150(1)⊕⊕⊕⊕
high
 

Brief Pain Inventory for Arthritis (0 being "no interference" and 10 being "interferes completely")

(follow-up: 4 months)

[Intervention:Counselling/Patient Education + Booklet]
Mean difference of scores ranged from -0.12 to -0.53 for different items between intervention and control group90(1)⊕⊕⊕⊕
high
 

Paediatric asthma quality of life questionnaire (PAQLQ) score (3 domains-emotion, activities and symptoms - score on each item ranged from 1 to 7, where 1 indicate maximum impairment and 7 indicates no impairment)

(follow-up: 9 weeks)

 

[Intervention: Counselling/Patient Education]
Mean difference on score for emotion, activities and symptom was 1.3, 2.1 and 1.7 respectively between intervention and control group21(1)⊕⊕⊕⊕
high
 

QOL (SF-36) for hyperlipidemia

(follow-up: 16 weeks)

[Interventions: Pharmaceutical plan with scheduled follow-up + Patient education + Booklet]
Statistically significant improvement in the QOL score in the intervention group as compared to control group**42(1)⊕⊕⊕⊝
moderate
The evidence was downgraded from high to moderate because 'risk of bias' was serious (due to unclear allocation concealment, attrition bias and selective reporting of outcome)

Overall Quality of Life (OQOL) (score from 0 to 30)

(follow-up: 5 months)

[Intervention: Counselling/Patient Education]
Mean difference of score of OQOL was +5.45 between intervention and control group154(1)⊕⊕⊕⊕
high

Diabetes Dependent Quality of Life questionnaire (ADDQOL)

(follow-up: 6 months)

 

[Intervention: Counselling/Patient Education + Booklet]
Statistically significant improvement in the QOL in the intervention group as compared to control group**70(1)⊕⊕⊕⊕
high
 

Health related Quality of Life Score (HRQOL) for Asthma/COPD

(follow-up: 6 months)

[Interventions: Pharmaceutical plan with scheduled follow-up + Patient education + Booklet]
Statistically significant improvement in the HRQOL in the intervention group as compared to control group**350(1)⊕⊕⊕⊝
moderate
The evidence was downgraded from high to moderate because 'risk of bias' was serious (as concealment of allocation was unclear and attrition bias was not addressed in the study)

Health Sevice Utilisation

Rate of Hospitalisation

(follow-up: mean 20.6 weeks)

[Intervention:Counselling/Patient Education + Booklet, Pharmaceutical plan with scheduled follow-up + Patient education + Booklet and Counselling + Drug Review]
Mean difference of percentage of rate of hospitalisation between intervention and control was -15.76%*500(3)⊕⊕⊕⊝
moderate
The evidence was downgraded from high to moderate because of risk of bias was serious (as concealment of allocation was not done in a study and attrition bias was not addressed in two studies)

Number of General Practitioner (GP) visit

(follow-up: mean 18.6 weeks)

[Interventions: Counselling/Patient Education + Booklet and Pharmaceutical plan with scheduled follow-up + Patient education + Booklet]
Mean difference of percentage of ‘need of GP visits for greater than 6 times’ parameter between intervention and control group ranged from 4.6% to 14%

Mean difference of percentage of ‘need of   GP visits for less than 2-3 times’ was 19.2% between intervention and control group.

Mean difference of “no need of visit to GP” parameter between intervention and control group was 16.3%
490(3)⊕⊕⊕⊝
moderate
The evidence was downgraded from high to moderate because 'risk of bias' was serious (as concealment of allocation was unclear in three studies and attrition bias was not addressed  in a single study)

Cost

Medication Cost

(follow-up: 6 months)

[Interventions: Pharmaceutical plan with scheduled follow-up + Patient education + Booklet]
Statistically significant reduction in cost between intervention and control group**350(1)⊕⊕⊕⊝
moderate
The evidence was downgraded from high to moderate because of risk of bias was serious (as concealment of allocation was unclear and attrition bias was not addressed in the study)

*Effect size reported of only a single study

**Effect size not reported

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.



 

Appendix 4. Result table 2(c) Comparison of the delivery of healthcare professional targeted services by pharmacists versus usual care


2(c) Comparison of the delivery of healthcare professional targeted services by pharmacists versus usual care

OutcomesImpactNo of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Asthma symptom score (0-9 score, where 9 indicates maximum impairment and 0 indicates no impairment)

(follow-up: 3 months)
Mean difference of asthma symptom score was -0.85 between intervention and control group43 general practices/

318 asthmatic children (1)
⊕⊕⊕⊕
high

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

Sami Pande: development of the protocol, developing search strategies, searching studies, accessing articles, reviewing of articles for inclusion and exclusion, abstraction of data for the included papers, interpretation of results and writing and editing of the review.

Janet E Hiller: assisted with the development of the protocol, access to articles, reviewing of articles for inclusion and exclusion, abstraction of data for the included papers, review and editing of all drafts, assistance with interpretation of results and approval of the final version of the review.

Nancy Nkansah: assisted with interpretation of data, provided general advice on the review, duplicate risk of bias assessment of the subset of studies, edited the review draft, assisted in accessing articles and approval of the final version of the review. 

Lisa Bero: study design, duplicate risk of bias assessment of the subset of studies, editing of review and approval of the final version of the review.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

Sami Pande: none

Janet E Hiller: none

Nancy Nkansah: none

Lisa Bero: none

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Contributions of authors
  14. Declarations of interest
  15. Characteristics of studies
  16. References to studies included in this review
  17. References to studies excluded from this review
  18. References to studies awaiting assessment
  19. Additional references
Abdelhamid 2008 {published data only}
  • Abdelhamid E, Awad A, Gismallah A. Evaluation of a hospital pharmacy-based pharmaceutical care services for asthma patients. Pharmacy Practice 2008, issue 1:25-32.
Adepu 2007 {published data only}
  • Adepu R, Rasheed A, Nagavi B. Effect of patient counseling on quality of life in type-2 diabetes mellitus patients in two selected South Indian community pharmacies: A study. Indian Journal of Pharmaceutical Sciences 2007; Vol. 69, issue 4:519-24.
Arun 2008 {published data only}
  • Arun K, Murugan R, Kanna M, Rajalakshmi S, Kalaiselvi R, Komathi V. The impact of pharmaceutical care on the clinical outcome of diabetes mellitus among a rural patient population. International Journal of Diabetes in Developing Countries 2008; Vol. 28, issue 1:15-8.
Ebid 2006 {published data only}
  • Ebid AH, Abdel-Wahab E. Bronchial asthma and COPD: Impact of pharmaceutical care on outcomes and quality of life in Egyptian patients. Bulletin of Pharmaceutical Sciences 2006; Vol. 29, issue Part 1:167-85.
Gonzalez-Martin 2003 {published data only}
  • Gonzalez-Martin G, Joo I, Sanchez I. Evaluation of the impact of a pharmaceutical care program in children with asthma. Patient Education and Counseling. 2003/01/16 2003; Vol. 49, issue 1:13-8. [0738-3991: (Print)]
Lugo 2007 {published data only}
  • Lugo De Ortellado G, de Bittner MR, Chavez H, Perez S. Implementation of a pharmaceutical care program for the detection of hypertension and drug therapy to be followed up in community pharmacies. Acta Farmaceutica Bonaerense 2007; Vol. 26, issue 4:590-5.
Paulos 2005 {published data only}
  • Paulos CP, Nygren CE, Celedon C, Carcamo CA. Impact of a pharmaceutical care program in a community pharmacy on patients with dyslipidemia. The Annals of Pharmacotherapy. 2005/04/14 2005; Vol. 39, issue 5:939-43. [1060-0280: (Print)]
Petkova 2008 {published data only}
  • Petkova VB. Pharmaceutical care for asthma patients: A community pharmacy-based pilot project. Allergy and Asthma Proceedings 2008; Vol. 29, issue 1:55-61.
Petkova 2009 {published data only}
  • Petkova VB. Education for arthritis patients: A community pharmacy based pilot project. Pharmacy Practice 2009; Vol. 7, issue 2:88-93.
Sookaneknun 2004 {published data only}
  • Sookaneknun P, Richards RM, Sanguansermsri J, Teerasut C. Pharmacist involvement in primary care improves hypertensive patient clinical outcomes. The Annals of Pharmacotherapy 2004, issue 12:2023-8.
Suppapitiporn 2005 {published data only}
  • Suppapitiporn S, Chindavijak B, Onsanit S. Effect of diabetes drug counseling by pharmacist, diabetic disease booklet and special medication containers on glycemic control of type 2 diabetes mellitus: a randomized controlled trial. Journal of the Medical Association of Thailand. 2006/04/21 2005; Vol. 88 Suppl 4:S134-41. [0125-2208: (Print)]
Zwarenstein 2007 {published data only}
  • Zwarenstein M, Bheekie A, Lombard C, Swingler G, Ehrlich R, Eccles M, et al. Educational outreach to general practitioners reduces children's asthma symptoms: A cluster randomised controlled trial. Implementation Science 2007; Vol. 2:30.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Contributions of authors
  14. Declarations of interest
  15. Characteristics of studies
  16. References to studies included in this review
  17. References to studies excluded from this review
  18. References to studies awaiting assessment
  19. Additional references
Abu 2009 {published data only}
  • Abu Rumman K, Ottmani S, Abu Sabra N, Baghdadi S, Seita A, Blanc L. Training on the practical approach to lung health: effect on drug prescribing in PHC settings in Jordan. Eastern Mediterranean Health Journal. 2009/05/28 2009; Vol. 15, issue 1:111-21. [1020-3397: (Print)]
Aguwa 2008 {published data only}
  • Aguwa CN, Ukwe CV, Ekwunife OI. Effect of pharmaceutical care programme on blood pressure and quality of life in a Nigerian pharmacy. Pharmacy World & Science. 2007/08/19 2008; Vol. 30, issue 1:107-10. [0928-1231: (Print)]
Agyepong 2002 {published data only}
  • Agyepong IA, Ansah E, Gyapong M, Adjei S, Barnish G, Evans D. Strategies to improve adherence to recommended chloroquine treatment regimes: a quasi-experiment in the context of integrated primary health care delivery in Ghana. Social Science & Medicine. 2002/11/01 2002; Vol. 55, issue 12:2215-26. [0277-9536: (Print)]
Akoria 2008 {published data only}
  • Akoria OA, Isah AO. Prescription writing in public and private hospitals in Benin City, Nigeria: the effects of an educational intervention. The Canadian Journal of Clinical Pharmacology. 2008/07/22 2008; Vol. 15, issue 2:e295-305. [1710-6222: (Electronic)]
Alam 2007 {published data only}
  • Alam K, Palaian S, Shankar RP, Bista D, Mishra P, Prabhu MM. Role of pharmacist in counseling asthma patients. Pharmacy Times 2007; Vol. 39, issue 6:13-8.
Anderson 2004 {published data only}
  • Anderson RJ. Cost analysis of a managed care decentralized outpatient pharmacy anticoagulation service. Journal of Managed Care Pharmacy 2004; Vol. 10, issue 2:159-65.
Angalakuditi 2003 {published data only}
  • Angalakuditi MV, Sunderland VB. Liquid medication dosing errors: A pre-post time series in India. International Journal of Pharmacy Practice 2003; Vol. 11, issue 2:105-10.
Angunawela, 1991 {published data only}
  • Angunawela II, Diwan VK, Tomson G. Experimental evaluation of the effects of drug information on antibiotic prescribing: a study in outpatient care in an area of Sri Lanka. International Journal of Epidemiology. 1991/06/01 1991; Vol. 20, issue 2:558-64. [0300-5771: (Print)]
Aramwit 2003 {published data only}
  • Aramwit P, Assawawitoontip S. Evaluation of patient counseling on blood pressure control of out-patients with hypertension at Chulalongkorn Hospital. Journal of the Medical Association of Thailand 2003; Vol. 86 Suppl 2:496-500.
Armando 2001 {published data only}
  • Armando PD, Semería N, Tenllado MI, Sola N. Dáder program in Argentina: Results of the first trimester activities. Pharmaceutical Care Espana 2001; Vol. 3, issue 3:196-203.
Armando 2005 {published data only}
  • Armando P, Semería N, Tenllado M, Sola N. Pharmacotherapeutic follow-up of patients in community pharmacies. Seguimiento Farmacoterapéutico de Pacientes en Farmacias Comunitarias 2005; Vol. 36, issue 3:129-34.
Awad 2006 {published data only}
  • Awad AI, Eltayeb IB, Baraka OZ. Changing antibiotics prescribing practices in health centers of Khartoum State, Sudan. European Journal of Clinical Pharmacology. 2006/01/04 2006; Vol. 62, issue 2:135-42. [0031-6970: (Print)]
Beaton 2004 {published data only}
  • Beaton SJ, Nag SS, Gunter MJ, Gleeson JM, Sajjan SS, Alexander CM. Adequacy of glycemic, lipid, and blood pressure management for patients with diabetes in a managed care setting. Diabetes Care 2004; Vol. 27, issue 3:694-8.
Birrell 2000 {published data only}
  • Birrell G, Birrell KG. Assessment of a 1-year teaching programme in Zanzibar, Tanzania. Lancet. 2000/09/29 2000; Vol. 356, issue 9235:1084. [0140-6736: (Print)]
Botha 1992 {published data only}
  • Botha JH, Tyrannes I, Miller R, Wesley AG. Pharmacokinetic consultation program in a pediatric asthma clinic. American Journal of Hospital Pharmacy 1992; Vol. 49, issue 8:1936-40.
Brimkulov 2009 {published data only}
  • Brimkulov N, Ottmani SE, Pio A, Chubakov T, Sultanova A, Davletalieva N, et al. Feasibility test results of the Practical Approach to Lung Health in Bishkek, Kyrgyzstan. The International Journal of Tuberculosis and Lung Disease. 2009/04/02 2009; Vol. 13, issue 4:533-9. [1027-3719: (Print)]
Castro-Rios 2008 {published data only}
  • Castro-Rios A, Reyes-Morales H, Perez-Cuevas R. [An evaluation of a continuing medical education program for primary care services in the prescription of hypoglycemic agents in diabetes mellitus type 2]. Salud Publica de Mexico. 2008/12/17 2008; Vol. 50 Suppl 4:S445-52. [1606-7916: (Electronic)]
Chaikoolvatana 2006 {published data only}
  • Chaikoolvatana A, Chanakit T, Juengrakpong A. The evaluation of a recurrent Adverse Drug Reaction Prevention Program in the north-east region of Thailand. Journal of the Medical Association of Thailand. 2006/06/08 2006; Vol. 89, issue 5:699-705. [0125-2208: (Print)]
Chaiyakunapruk 2006 {published data only}
  • Chaiyakunapruk N, Laowakul A, Karnchanarat S, Pikulthong N, Ongphiphadhanakul B. Community pharmacy-based implementation and evaluation of an osteoporosis self-assessment tool for Asians. Journal of the American Pharmaceutical Association. 2006/06/03 2006; Vol. 46, issue 3:391-6. [1544-3191: (Print)]
De Andrade 2009 {published data only}
  • De Andrade TU, Burini DM, Mello MDO, Bersácula NDS, Saliba RAD, Bravim FT, et al. Evaluation of the satisfaction level of patients attended by a pharmaceutical care program in a private communitarian pharmacy in Vitória (ES, Brazil). Revista Brasileira de Ciencias Farmaceuticas/Brazilian Journal of Pharmaceutical Sciences 2009; Vol. 45, issue 2:349-55.
De Lyra 2008 {published data only}
  • De Lyra Jr DP, Marcellini PS, Pelá IR. Effect of pharmaceutical care intervention on blood pressure of elderly outpatients with hypertension. Revista Brasileira de Ciencias Farmaceuticas/Brazilian Journal of Pharmaceutical Sciences 2008; Vol. 44, issue 3:451-7.
De Souza 2007 {published data only}
  • De Souza WA, Yugar-Toledo JC, Bergsten-Mendes G, Sabha M, Moreno Jr H. Effect of pharmaceutical care on blood pressure control and health-related quality of life in patients with resistant hypertension. American Journal of Health-System Pharmacy 2007; Vol. 64, issue 18:1955-61.
Domecq 1991 {published data only}
  • Domecq C, Apud P, Paulos C. Evaluation of an educational program on ambulatory patients consuming histamine H2-receptor antagonists. Acta Farmaceutica Bonaerense 1991; Vol. 10, issue May-Aug:97-104.
Dowse 2001 {published data only}
  • Dowse R, Ehlers MS. The evaluation of pharmaceutical pictograms in a low-literate South African population. Patient Education and Counseling 2001; Vol. 45, issue 2:87-99.
Dowse 2005 {published data only}
  • Dowse R, Ehlers M. Medicine labels incorporating pictograms: do they influence understanding and adherence?. Patient Education and Counseling. 2005/06/14 2005; Vol. 58, issue 1:63-70. [0738-3991: (Print)]
Dubey 2006 {published data only}
  • Dubey AK, Palaian S, Shankar PR, Mishra P, Prabhu M, Bhandari RB, et al. Introduction to medication errors and the error prevention initiatives in a teaching hospital in Western Nepal. Pakistan Journal of Pharmaceutical Sciences 2006; Vol. 19, issue 3:244-51.
Eltayeb 2005 {published data only}
  • Eltayeb IB, Awad AI, Mohamed-Salih MS, Daffa-Alla MA, Ahmed MB, Ogail MA, et al. Changing the prescribing patterns of sexually transmitted infections in the White Nile Region of Sudan. Sexually Transmitted Infections. 2005/10/04 2005; Vol. 81, issue 5:426-7. [1368-4973: (Print)]
Erhun 2005 {published data only}
  • Erhun WO, Agbani EO, Bolaji EE. Positive benefits of a pharmacist-managed hypertension clinic in Nigeria. Public Health 2005, issue 9:792-8.
Esmaily 2009 {published data only}
  • Esmaily HM, Savage C, Vahidi R, Amini A, Dastgiri S, Hult H, et al. Does an outcome-based approach to continuing medical education improve physicians' competences in rational prescribing?. Medical Teacher. 2009/11/17 2009; Vol. 31, issue 11:e500-6. [1466-187X: (Electronic)]
Garjani 2009 {published data only}
  • Garjani A, Salimnejad M, Shamsmohamadi M, Baghchevan V, Vahidi RG, Maleki-Dijazi N, et al. Effect of interactive group discussion among physicians to promote rational prescribing. Eastern Mediterranean Health Journal. 2009/06/27 2009; Vol. 15, issue 2:408-15. [1020-3397: (Print)]
Gonzalez 1996a {published data only}
  • Gonzalez Ochoa E, Armas Perez L, Bravo Gonzalez JR, Cabrales Escobar J, Rosales Corrales R, Abreu Suarez G. Prescription of antibiotics for mild acute respiratory infections in children. Bulletin of the Pan American Health Organization. 1996/06/01 1996; Vol. 30, issue 2:106-17. [0085-4638: (Print)]
Greenberg 2005 {published data only}
  • Greenberg HM, Galyavich AS, Ziganshina LE, Tinchurina MR, Chamidullin AG, Farmer RG. Identification and management of patients with hypertension in the polyclinic system of the Russian Federation. American Journal of Hypertension 2005; Vol. 18, issue 7:943-8.
Gupta 2005 {published data only}
  • Gupta U, Sharma S, Sheth PD, Jha J, Chaudhury RR. Improving medicine usage through patient information leaflets in India. Tropical Doctor. 2005/08/18 2005; Vol. 35, issue 3:164-6. [0049-4755: (Print)]
Gutierrez 1994 {published data only}
  • Gutierrez G, Guiscafre H, Bronfman M, Walsh J, Martinez H, Munoz O. Changing physician prescribing patterns: evaluation of an educational strategy for acute diarrhea in Mexico City. Medical Care. 1994/05/01 1994; Vol. 32, issue 5:436-46. [0025-7079: (Print)]
Jing 2009 {published data only}
  • Jing YS, Lai PSM, Siew SC, Siew PC. The impact of pharmacist intervention on the use of activated vitamin D in a tertiary referral hospital in Malaysia. International Journal of Pharmacy Practice 2009; Vol. 17, issue 5:305-11.
Lyra 2007 {published data only}
  • Lyra DP Jr, Rocha CE, Abriata JP, Gimenes FR, Gonzalez MM, et al. Influence of Pharmaceutical Care intervention and communication skills on the improvement of pharmacotherapeutic outcomes with elderly Brazilian outpatients. Patient Education and Counseling. 2007/08/19 2007; Vol. 68, issue 2:186-92. [0738-3991: (Print)]
Mao 2008 {published data only}
  • Mao Y, Zhang Y, Zhai S. Mobile phone text messaging for pharmaceutical care in a hospital in China. Journal of Telemedicine and Telecare 2008; Vol. 14, issue 8:410-4.
Me'emary 2009 {published data only}
  • Me'emary F, Ottmani SE, Pio A, Baghdadi S, Assafin G, Koraym M, et al. Results of the feasibility test of the Practical Approach to Lung Health in the Syrian Arab Republic. Eastern Mediterranean Health Journal. 2009/09/08 2009; Vol. 15, issue 3:504-15. [1020-3397: (Print)]
Meyer 2001 {published data only}
  • Meyer JC, Summers RS, Moller H. Randomized, controlled trial of prescribing training in a South African province. Medical Education. 2001/09/14 2001; Vol. 35, issue 9:833-40. [0308-0110: (Print)]
Mohagheghi 2005 {published data only}
  • Mohagheghi MA, Mosavi-Jarrahi A, Khatemi-Moghaddam M, Afhami S, Khodai S, Azemoodeh O. Community-based outpatient practice of antibiotics use in Tehran. Pharmacoepidemiology and Drug Safety. 2005/01/05 2005; Vol. 14, issue 2:135-8. [1053-8569: (Print)]
Nascimento 2009 {published data only}
  • Nascimento YDA, Carvalho WDS, Acurcio FDA. Drug-related problems observed in a pharmaceutical care service, Belo Horizonte, Brazil. Revista Brasileira de Ciencias Farmaceuticas/Brazilian Journal of Pharmaceutical Sciences 2009; Vol. 45, issue 2:321-30.
Ngoh 1997 {published data only}
  • Ngoh LN, Shepherd MD. Design, development, and evaluation of visual aids for communicating prescription drug instructions to nonliterate patients in rural Cameroon. Patient Education and Counseling. 1997/03/01 1997; Vol. 30, issue 3:257-70. [0738-3991: (Print)]
Odusanya 2004 {published data only}
  • Odusanya OO, Oyediran MA. The effect of an educational intervention on improving rational drug use. The Nigerian Postgraduate Medical Journal 2004; Vol. 11, issue 2:126-31.
Ofori-Adjei 1996 {published data only}
  • Ofori-Adjei D, Arhinful DK. Effect of training on the clinical management of malaria by medical assistants in Ghana. Social Science & Medicine. 1996/04/01 1996; Vol. 42, issue 8:1169-76. [0277-9536: (Print)]
Oparah 2006 {published data only}
  • Oparah AC, Adje DU, Enato EFO. Outcomes of pharmaceutical care intervention to hypertensive patients in a Nigerian community pharmacy. International Journal of Pharmacy Practice 2006; Vol. 14, issue 2:115-22.
Osiri 2001 {published data only}
  • Osiri S, Richards M. Primary care treatment of upper respiratory tract infections in NE Thailand by pharmacists and physicians. Journal of Social and Administrative Pharmacy 2001; Vol. 18, issue 6:232-8.
Pankonin 2008 {published data only}
  • Pankonin CA, Higgs P, Reid G, Aitken C. Selling syringes to injecting drug users: a study of five pharmacies in Hanoi, Vietnam. Journal of Infection in Developing Countries. 2008/01/01 2008; Vol. 2, issue 1:51-8. [1972-2680: (Electronic)]
Park 2007 {published data only}
  • Park JS, Ahn CW. Educational program for diabetic patients in Korea--multidisciplinary intensive management. Diabetes Research and Clinical Practice. 2007/04/24 2007; Vol. 77 Suppl 1:S194-8. [0168-8227: (Print)]
Perera 1988 {published data only}
  • Perera UA, Angunawela I. Basic drug information to patients attending medical clinics of a teaching hospital. The Ceylon Medical Journal. 1988/03/01 1988; Vol. 33, issue 1:27-9. [0009-0875: (Print)]
Perez 2003 {published data only}
  • Perez A, Dennis RJ, Rodriguez B, Castro AY, Delgado V, Lozano JM, et al. An interrupted time series analysis of parenteral antibiotic use in Colombia. Journal of Clinical Epidemiology. 2003/10/22 2003; Vol. 56, issue 10:1013-20. [0895-4356: (Print)]
Perez-Cuevas 1996 {published data only}
  • Perez-Cuevas R, Guiscafre H, Munoz O, Reyes H, Tome P, Libreros V, et al. Improving physician prescribing patterns to treat rhinopharyngitis. Intervention strategies in two health systems of Mexico. Social Science & Medicine. 1996/04/01 1996; Vol. 42, issue 8:1185-94. [0277-9536: (Print)]
Petkova 2005 {published data only}
  • Petkova V. Evaluation of the impact of a pharmaceutical care program on patients with asthma. Ankara Universitesi Eczacilik Fakultesi Dergisi 2005; Vol. 34, issue 4:251-62.
Petkova 2006 {published data only}
  • Petkova V, Ivanova A, Petrova G. Education of patients with diabetes in the community pharmacies (pilot project in Bulgaria). Ankara Universitesi Eczacilik Fakultesi Dergisi 2006; Vol. 35, issue 2:111-24.
Ratanajamit 2009 {published data only}
  • Ratanajamit C, Kaewpibal P, Setthawacharavanich S, Faroongsarng D. Effect of pharmacist participation in the health care team on therapeutic drug monitoring utilization for antiepileptic drugs. Journal of the Medical Association of Thailand 2009; Vol. 92, issue 11:1500-7.
Rivera 2006 {published data only}
  • Rivera S, Lopez Orozco M. Design, implementation and assessment of a health education service on the correct use of drugs in a pediatric Mexican hospital. Diseño, Implementación y Evaluación de un Servicio de Educación Sanitaria Sobre el Uso Correcto de los Medicamentos en un Hospital Pediátrico Mexicano 2006; Vol. 4, issue 1:9-12.
Rosen 1978 {published data only}
  • Rosen CE, Copp WM, Holmes S. Effectiveness of a specially trained pharmacist in a rural community mental health center. Public Health Reports 1978; Vol. 93, issue 5:464-7.
Rosen 1978a {published data only}
  • Rosen CE, Holmes S. Pharmacist's impact on chronic psychiatric outpatients in community mental health. American Journal of Hospital Pharmacy. 1978/06/01 1978; Vol. 35, issue 6:704-8. [0002-9289: (Print)]
Santos 2006 {published data only}
  • Santos AC, Pereira DA, Da Silva OA, Lopes LC. Pharmacotherapeutic follow-up for patients with pulmonary tuberculosis with Dáder method. Seguimento Farmacoterapêutico em Pacientes com Tuberculose Pulmonar Através da Metodologia Dáder 2006; Vol. 27, issue 3:269-73.
Santoso 1996 {published data only}
  • Santoso B, Suryawati S, Prawaitasari JE. Small group intervention vs formal seminar for improving appropriate drug use. Social Science & Medicine. 1996/04/01 1996; Vol. 42, issue 8:1163-8. [0277-9536: (Print)]
Suryaprakasha 1983 {published data only}
  • Suryaprakasha Rao P. Hospital pharmacist in geriatric care. Indian Journal of Hospital Pharmacy 1983; Vol. 20, issue 6:229-34.
Turnacilar 2009 {published data only}
  • Turnacilar M, Sancar M, Apikoglu-Rabus S, Hursitoglu M, Izzettin FV. Improvement of diabetes indices of care by a short pharmaceutical care program. Pharmacy World and Science 2009; Vol. 31, issue 6:689-95.
Udomthavornsuk 1991 {published data only}
  • Udomthavornsuk B, Tatsanavivat P, Patjanasoontorn B, Khomthong R, Bhuripanyo K, Saengnipanthkul S, et al. Intervention of inappropriate antibiotic use at a university teaching hospital. Journal of the Medical Association of Thailand. 1991/10/01 1991; Vol. 74, issue 10:429-36. [0125-2208: (Print)]
Wood 2008 {published data only}
  • Wood R, Kaplan R, Bekker LG, Brown S, Rivett U. The utility of pharmacy dispensing data for ART programme evaluation and early identification of patient loss to follow-up. Southern African Journal of HIV Medicine 2008, issue 30:44-50.

References to studies awaiting assessment

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Contributions of authors
  14. Declarations of interest
  15. Characteristics of studies
  16. References to studies included in this review
  17. References to studies excluded from this review
  18. References to studies awaiting assessment
  19. Additional references
Adisa 2012 {published data only}
  • Adisa R, Fakeye T O. Pharmacists-based intervention strategies to address compliance problems among poorly controlled type 2 diabetes in ambulatory care settings in Nigeria. International Journal of Pharmacy Practice 2012;20:41-2.
AJP 2011 {published data only}
  • Pharmacist intervention improves patient adherence to antidepressants. Australian Journal of Pharmacy 2011;92:100.
Azzopardi 2010 {published data only}
  • Azzopardi L, Hudson S, Mallia C, Cassar K, Coleiro B, Cassar P J, et al. Pharmaceutical care for rheumatoid arthritis patients on methotrexate attending an outpatient hospital clinic. Rheumatology 2010;49:i130.
Correr 2011 {published data only}
  • Correr C J, Melchiors A C, Fernandez-Llimos F, Pontarolo R. Effects of a pharmacotherapy follow-up in community pharmacies on type 2 diabetes patients in Brazil. International journal of clinical pharmacy [Online] 2011; Vol. 33:273-80. Available: http://www.mrw.interscience.wiley.com/cochrane/clcentral/articles/381/CN-00812381/frame.html..
Costa 2012 {published data only}
  • Costa C G R, Carnevale R C, Holsback V S S, Braz N C, Santos C Z, Moriel P, et al. Can a year of pharmacotherapeutic follow-up reduce the incidence of drug-related problems and increase CD4 counts in HIV-positive outpatients?. European Journal of Hospital Pharmacy: Science and Practice 2012;19:228.
Dewulf 2011 {published data only}
  • Dewulf N L, Santos V D, Pereira L R, Troncon L E. A structured program of pharmaceutical care benefits outpatients with inflammatory bowel diseases undergoing continuous drug therapy. International Journal of Clinical Pharmacy 2011;140:S207.
Dewulf 2012 {published data only}
  • Dewulf N D L S, Santos V, Pereira L, Troncon L E D A. A structured pharmaceutical care program benefits outpatients with inflammatory bowel diseases. Gastroenterology 2012;34:212.
Fahimi 2011 {published data only}
  • Fahimi F, Sharif-Kashani B, Hossein-Ahmadi Z, Salamzadeh J, Namdar R, Mousavi S, et al. The first pharmacist-based warfarin-monitoring service in Iran. Journal of Pharmaceutical Health Services Research 2011;2:59-62.
Farsaei 2011 {published data only}
  • Farsaei S, Sabzghabaee A M, Zargarzadeh A H, Amini M. Effect of pharmacist-led patient education on glycemic control of type 2 diabetics: A randomized controlled trial. Journal of Research in Medical Sciences 2011;16:43-9.
Fuchs 2010 {published data only}
  • Fuchs S C, Fuchs F D, Moreira L B, Gus M, Wiehe M, Fuchs F C, et al. Efficacy of home blood pressure monitoring on blood pressure control: A randomized controlled trial. Circulation 2010;122:e78.
Lavoie 2011 {published data only}
  • Lavoie K, Moullec G, Blais L, Beauchesne M F, Lemiere C, Labrecque M, et al. The efficacy of brief motivational interviewing to improve medication adherence in poorly controlled, nonadherent asthmatics: Results from a randomised controlled pilot study. Chest 2011;140:915A.
Lee 2012 {published data only}
  • Lee W Y, Chan M C, Cheun T K, So K H, Yu C M. Impact of pharmacist counselling service on blood pressure control of borderline hypertensive patients. European Heart Journal 2012;14:A25.
Lores 2011 {published data only}
  • Lores Delgado D, Lazo Roblejo Y, Bermudez Camps I B, Zuniga Moro A. Pharmacotherapeutic monitoring in patients with congestive heart failure, dispensarized at the Principal Municipal Pharmacy at Santiago de Cuba. Pharmaceutical Care Espana 2011;13:114-22.
Magedanz 2012 {published data only}
  • Magedanz L, Silliprandi E M, dos Santos R P. Impact of the pharmacist on a multidisciplinary team in an antimicrobial stewardship program: a quasi-experimental study. Int J Clin Pharm 2012;34:290-4.
Malaty 2011 {published data only}
  • Malaty J, Cook S, Green C. Influence of a pharmacist initiated educational intervention on patients' utilization of fluconazole for vulvovaginal candidiasis in an outpatient setting. Journal of the American Pharmacists Association 2011;51:299-300.
Maria 2012 {published data only}
  • Maria Belen F I M B, Jose Manuel F O J M, Isabel M C I, Cristina G P C, Angeles F C A, Elena S Y E, et al. The improvement of adherence to antiretroviral treatment through the pharmaceutical care and the analysis of factors affecting it. European Journal of Hospital Pharmacy: Science and Practice 2012;19:242.
Mohammad 2011 {published data only}
  • Mohammad R A, Kim J J, Donihi A C, Coley K. Impact of hospital-based pharmacist advocates in care transitions: Identification and description of medication related interventions after patient discharge from hospital to home. Pharmacotherapy 2011;31:388e.
Mori 2010 {published data only}
  • Mori Alpm, Heimann J C, Dorea E L, Bernik M M S, Storpirtis S. Pharmaceutic guidance to hypertensive patients at USP University Hospital: effect on adherence to treatment. Brazilian Journal of Pharmaceutical Sciences [Online] 2010; Vol. 46:353-62. Available: http://www.mrw.interscience.wiley.com/cochrane/clcentral/articles/752/CN-00789752/frame.html.
Moten 2010 {published data only}
  • Moten M, Barner J, Jokerst J. Medication therapy management and diabetes outcomes of diabetic patients who receive clinical pharmacy services. Journal of the American Pharmacists Association 2010;50:312.
Ola-Olorun 2012 {published data only}
  • Ola-Olorun O J, Afolabi M O, Ogunsina A O, Oyebisi T O, Akinyemi O A, Akintomide A O, et al. Exploring medicine information needs of hypertensive patients using short message service (SMS) of mobile phone. Pharmacoepidemiology and Drug Safety 2012;21:116.
Olives 2012 {published data only}
  • Olives T D, Patel R G, Nelson R S, Yew A, Joing S, Miner J R. Randomized controlled trial of three instructional modalities for patients prescribed outpatient antibiotics from the ED: The potential of cell phone technology to reach limited health literacy patients. Academic Emergency Medicine 2012;19:S219.
Pinelli 2012 {published data only}
  • Pinelli N R, Clark L M, Malinzak L, Goggins M, Patel A. Pharmacist-managed diabetes and cardiovascular risk reduction clinic in renal transplant recipients: Preliminary findings. American Journal of Transplantation 2012;12:288-9.
Saokaew 2012 {published data only}
  • Saokaew S, Sapoo U, Nathisuwan S, Chaiyakunapruk N, Permsuwan U. Anticoagulation control of pharmacist-managed collaborative care versus usual care in Thailand. Int J Clin Pharm 2012;34:105-12.
Shapiro 2010 {published data only}
  • Shapiro L. Pharmacist intervention boosts patient compliance. Drug Topics 2010;154:27.
Tahaineh 2011 {published data only}
  • Tahaineh L, Albsoul-Younes A, Al-Ashqar E, Habeb A. The role of clinical pharmacist on lipid control in dyslipidaemic patients in North of Jordan. International journal of clinical pharmacy [Online] 2011; Vol. 33:229-36. Available: http://www.mrw.interscience.wiley.com/cochrane/clcentral/articles/801/CN-00810801/frame.html.
Tse 2011 {published data only}
  • Tse T, Althunian T, Burrows J, Yang I, Masel P. An evaluation of the role and potential benefits of the clinical pharmacists involvement in respiratory outpatient clinic. Respirology 2011;16:52.

Additional references

  1. Top of page
  2. AbstractRésumé
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Contributions of authors
  14. Declarations of interest
  15. Characteristics of studies
  16. References to studies included in this review
  17. References to studies excluded from this review
  18. References to studies awaiting assessment
  19. Additional references
Aderemi-Williams 2007
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Anderson 2002
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APAaNAoCDS 2008
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Beney 2000
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Blenkinsopp 2003
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Christensen 2006
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Fabricant 1987
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FIP 1997
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Geest 1982
  • van der Geest S. The illegal distribution of western medicines in developing countries: pharmacists, drug pedlars, injection doctors and others. a bibliographic exploration. Medical Anthropology 1982:197-216.
Geest 1987
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Ghani 2010
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Hepler 1990
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Holloway 2006
  • Holloway K. Promoting rational use of medicines. International Network for Rational Use of Drugs News 2006; Vol. 16, issue 1:3-4.
Horn 2006
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Kaboli 2006
  • Kaboli P, Hoth A, McClimon B, Schnipper J. Clinical pharmacists and inpatient medical care: a systematic review. Archives of Internal Medicine 2006; Vol. 166, issue 9:955-64.
Kamat 1998
  • Kamat VR, Nitcher M. Self-Medication And Pharmaceutical Marketing in Bombay, India. Social Science & Medicine 1998; Vol. 47, issue 6:779-94.
Kane 2003
  • Kane S, Weber R, Dasta J. The impact of critical care pharmacists on enhancing patient outcomes. Intensive Care Medicine 2003; Vol. 29, issue 5:691-8.
le Grand 1999
  • Grand AL, Hogerzeil HV, Haaijer-Ruskamp FM. Intervention research in rational use of drugs: a review. Health Policy and Planning 1999; Vol. 14, issue 2:89-102.
Lipton 1992
  • Lipton H, Bero L, Bird J, McPhee S. The impact of clinical pharmacists' consultation on physicians geriatric drug prescribing. A randomized controlled trial. Medical Care 1992; Vol. 30, issue 7:646-58.
Lipton 1994
  • Lipton H, Bird J. The impact of clinical pharmacists' consultations on geriatric patients' compliance and medical care use: a randomized controlled trial. Gerontologist 1994; Vol. 34, issue 3:307-15.
Nkansah 2010
  • Nkansah N, Mostovetsky O, Yu C, Chheng T, Beney J, Bond CM, et al. Effect of outpatient pharmacists’ non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database of Systematic Reviews 2010, issue 7:CD000336.
Royal 2006
  • Royal S, Smeaton L, Avery A, Hurwitz B, Sheikh A. Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis. Quality & Safety in Health Care 2006; Vol. 15, issue 1:23-31.
Singhal 1999
  • Singhal P, Raisch D, Gupchup G. The impact of pharmaceutical services in community and ambulatory care settings: evidence and recommendations for future research. The Annals of Pharmacotherapy 1999; Vol. 33, issue 12:1336-55.
Smith 2009
  • Smith F. The quality of private pharmacy services in low and middle-income countries: a systematic review. Pharmacy World & Science 2009; Vol. 31, issue 3:351-61.
Tully 2000
  • Tully M, Seston E. Impact of pharmacists providing a prescription review and monitoring service in ambulatory care or community practice. The Annals of Pharmacotherapy 2000; Vol. 34, issue 11:1320-31.
WHO 1994
  • WHO. The role of the pharmacist in the health care system. World Health Organization. Geneva: World Health Organization (WHO), 1994.
WHO 1997
  • WHO. The role of pharmacist in the health care system. World Health Organization. Geneva: World Health Organization (WHO), 1997.
WHO 1998
  • WHO. The role of the pharmacist in self-Care and self-medication. World Health Organization. Geneva: Department of Essential Drugs and Other Medicines World Health Organization, 1998.
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  • World Bank Group. Country and lending groups. The World Bank Group. The World Bank Group, 2009.