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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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Characteristics of included studies [ordered by study ID]
Abdelhamid 2008

MethodsRandomised controlled trial

Unit of randomisation and analysis: patient


ParticipantsShaab Teaching Hospital, Khartoum, Sudan (lower middle income country)

Asthmatic patients of emergency department or referral clinic

patients - 100 (60 intervention group, 40 control group)

provider (delivering intervention) - 1

practice - 1
no unit of analysis error


Interventionstargeted towards PATIENTS

Drug therapy of asthma was reviewed by pharmacist according to the British Thoracic Society Guideline. In addition, educational program on disease, non-drug therapy measures, pharmacotherapy, self-management and inhalation technique were also delivered. versus usual care

Length of each intervention: Not clear

Number of intervention episodes: every 2 weeks for 22 weeks


OutcomesPATIENT     

1) Peak expiratory flow rate

PROCESS

1) Rate of hospitalisation


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo description of sequence generation

Allocation concealment (selection bias)High riskSample was randomly selected from those attended the emergency department or referral clinic

Baseline outcomes similar?Low riskPeak expiratory rate was similar

Baseline characteristics similar?Unclear riskStatistical analysis of variables were not reported and some of the differences look large

Blinding (performance bias and detection bias)Low riskObjective outcomes

Protection against contamination?High riskRandomisation by patient in a single centre

Incomplete outcome data (attrition bias)
All outcomes
High riskPatients lost but no description of how this taken into account in analysis

Selective reporting (reporting bias)Low riskAll outcomes listed in methods were reported in results

Free from other bias?Low riskNone identified

Adepu 2007

MethodsRandomised controlled trial

Unit of randomisation and analysis: patient


ParticipantsTwo community pharmacies in Calicut and Kerala in India (lower middle income country)

Type-2 diabetes mellitus patients

patients - 70 (35 intervention group, 35 control group)

provider (delivering intervention) - not clear

practice - 2
no unit of analysis error


Interventionstargeted towards PATIENTS

Intervention group received counselling on diabetes mellitus, medication, diet and lifestyle modifications along with the patient information leaflet explaining disease, diet and lifestyle modifications.vs. Usual care

Length of each intervention: Not clear

Number of intervention episodes: It is not clear; however, study was conducted for 6 months.

Unit of analysis error: Not clear


OutcomesPATIENT

1) Random capillary blood glucose measurement

2) Assessment of the quality of life by administering a disease-specific audit of Diabetes Dependent Quality of Life questionnaire (ADDQOL) including 18 life domain along with the two additional over view questions. 18 life domains such as freedom to eat, freedom to drink and enjoyment of food, family life, sex life, ease of travelling, working life and finance were included


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo description provided

Allocation concealment (selection bias)Unclear riskNot explicitly described

Baseline outcomes similar?Unclear riskGlucose levels different at baseline, but not clear is statistically significance

Baseline characteristics similar?Low riskDemographic values, disease history duration and treatment aspect were similar between the groups

Blinding (performance bias and detection bias)Low riskObjective outcomes

Protection against contamination?High riskCommunication between groups was possible as patients were randomised

Incomplete outcome data (attrition bias)
All outcomes
Low riskIntervention: 32 patients completed the study

Control: 28 patients completed the study

Selective reporting (reporting bias)Low riskAll outcomes listed in methods were reported in results

Free from other bias?Low riskNone identified

Arun 2008

MethodsRandomised controlled trial              

Unit of randomisation and analysis: patient


ParticipantsThree primary health centres in Northern Tamil Nadu, India (lower middle income country)

Type-2 diabetes patients

patients - 154 ( 104 intervention group, 50 control group)

provider (delivering intervention) - not clear

practice - 3

unit of analysis error: not clear


Interventionstargeted towards PATIENT

Counselling delivered by pharmacist (content of counselling is not explicitly described) versus usual care

Length of each intervention: not clear

Number of intervention episodes: intervention was delivered every month over 5 months


OutcomesPATIENT     

1) Fasting plasma glucose level (mg/dl)

2) Health related Quality of life (HRQoL) was assessed using Ferrans and Powers questionnaire (0-30 score range)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot explicitly described

Allocation concealment (selection bias)Unclear riskNot explicitly described

Baseline outcomes similar?Low riskBlood pressure between control and intervention group was similar

Baseline characteristics similar?Low riskDemographic values were similar between the groups

Blinding (performance bias and detection bias)Low riskObjective outcomes

Protection against contamination?High riskTwo people from same family or friends could have been assigned to different group as the study was conducted by randomising patients

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskOnly numbers of patients who completed study given

Selective reporting (reporting bias)Low riskAll outcomes listed in methods reported in results

Free from other bias?Low riskData was collected from the patients from someone other than the pharmacist doing the intervention

Ebid 2006

MethodsRandomised controlled trial              

Unit of randomisation and analysis: patient


ParticipantsUniversity affiliated outpatient pharmacy of EL-Demerdash Teaching Hospital Cairo, Egypt (lower middle income country)

Patients with asthma or chronic obstructive pulmonary disease (COPD)

patients - asthmatic patients 200 ( 100 intervention group, 100 control group); patients with COPD 150 (75 intervention group, 75 control group)

provider (delivering intervention) - not clear

practice - 1

no unit of analysis error


Interventionstargeted towards PATIENTS

Pharmaceutical-care, which includes educational session on disease, planning goals, medication, and mode of action of drug, side-effects and risk-factors for disease was provided. In addition, 12-paged booklet consisting of essential information on asthma/COPD, self-care and management was also provided. Asthmatic patients and patients with COPD were educated separately versus usual care

Length of each intervention: Education session consisting of 2 hours baseline interview of 5 to 8 persons followed by individual session of 20-30 minutes

Number of intervention episodes: every month over 6 months (6 times)


OutcomesPATIENTS

1) Health Related Quality of Life (HRQOL) score

PROCESS

1) Number of visits to Private clinics (PCs) or Outpatient clinics (OCs)

2) Number of Emergency Room (ER) visits and hospitalisation


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot explicitly described

Allocation concealment (selection bias)Unclear riskNot explicitly described

Baseline outcomes similar?Unclear riskDifferences in baseline measurements for primary outcomes was not reported

Baseline characteristics similar?Low riskDemographic values, smoking pattern, duration of disease were similar between the intervention and control group

Blinding (performance bias and detection bias)Low riskthe technical staff did not know whether the patients belonged to the control or intervention group and the outcome was objective

Protection against contamination?High riskSingle centre trial

Incomplete outcome data (attrition bias)
All outcomes
High riskNo data reported or imputed for patients lost to follow-up

Selective reporting (reporting bias)Low riskOutcomes listed in methods were reported in results

Free from other bias?Low riskNone identified

Gonzalez-Martin 2003

MethodsRandomised controlled trial               

Unit of randomisation and analysis: patient


ParticipantsOutpatient clinic of the Department of Pediatrics of the Catholic University of Chile (upper-middle income country)

Children with stable and  moderate asthma as defined by the American Thoracic Society Guidelines who were scheduled for outpatient visits with their internist over one year period

patients 21 (11 intervention group, 10 control group)

provider (delivering intervention) - not clear

practice - 1

no unit of analysis error


Interventionstargeted towards PATIENTS

Face to face educational session on asthma, medication therapy, self-management, inhalation techniques along with the provision of explanatory booklet illustrating all these topics versus usual care

Length of each intervention: 30 minutes

Number of intervention episodes: 3 over 9 weeks


OutcomesPATIENTS

1) Pediatric asthma quality of life questionnaire (PAQLQ) assessment which includes three domains i.e.  emotion, activities limitation and symptoms - score on each item ranged from 1 to 7, where 1 indicate maximum impairment and 7 indicates no impairment

2) Spirometric value measurement: Forced vital capacity (FVC) and forced expiratory flow (FEV)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot explicitly described

Allocation concealment (selection bias)Unclear riskNot explicitly described

Baseline outcomes similar?Low riskDifference was not statistically significant for mean age, FEV1, emotion, score, activities score, and symptom score.

Baseline characteristics similar?Low riskClinical characteristics were similar between the intervention and control group

Blinding (performance bias and detection bias)Low riskObjective outcomes

Protection against contamination?High riskIntervention and control groups were treated in the same clinic

Incomplete outcome data (attrition bias)
All outcomes
Low riskAll 21 participants enrolled completed the study

Selective reporting (reporting bias)Low riskOutcomes listed in methods were reported in results

Free from other bias?Low riskNone identified

Lugo 2007

MethodsRandomised controlled trial               

Unit of randomisation and analysis: patient


ParticipantsFour community pharmacies in Paraguay (lower-middle income country)

Hypertensive patients

patients - 70 ( 35 intervention group, 35 control group)

provider (delivering intervention) - not clear

practice - 4

no unit of analysis error


Interventionstargeted towards PATIENT

Patients received the program (pharmaceutical follow-up) over 6 months with each patient’s care and recommended advice recorded. Pharmaceutical care was based on Hepler and Strand 1990, which includes interviews, counselling and educational session with patients regarding medication and healthy lifestyle. Forms were also provided to the patients to record their medicine usage. Provision of periodic outcome measurement, counselling and distribution of education pamphlets along with a basket of healthy food to encourage healthy lifestyle versus usual care

Length of each intervention: not clear

Number of intervention episodes: It is not clear; however, study was conducted for 6 months


OutcomesPATIENTS

Blood pressure

1) Systolic

2) Diastolic

3) Distribution of patients in various categories of hypertension.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot explicitly described

Allocation concealment (selection bias)Unclear riskNot explicitly described

Baseline outcomes similar?Unclear riskNot explicitly mentioned

Baseline characteristics similar?High riskdifferent hypertension histories

Blinding (performance bias and detection bias)Low riskObjective outcomes

Protection against contamination?Unclear riskChances of contamination

Incomplete outcome data (attrition bias)
All outcomes
Low riskComplete outcome data reported

Selective reporting (reporting bias)Unclear riskdata not clearly provided for intervention and control group for all outcomes

Free from other bias?Low riskNone identified

Paulos 2005

MethodsRandomised controlled trial

Unit of randomisation and analysis: patient


ParticipantsA community pharmacy in Santiago, Chile (upper-middle income country)

Patients being treated for dyslipidemia

patients - 42 ( 23 intervention group, 19 control group)

provider (delivering intervention) - 1

practice -1

no unit of analysis error


Interventionstargeted towards PATIENT

Intervention includes complete pharmaceutical plan with scheduled follow-up. Pharmaceutical care includes:

i. Measuring total cholesterol level and triglycerides level

ii. Providing educational session/counselling to patients about the role of cholesterol in illness and health, risk-factors associated with cardiovascular disease and medication

iii. In each interview, drug-related problems (DRP) were also determined, resolved and prevented based on the information obtained from the patients and medical records. Patients detected with DRP were referred to a physician

iv. Specifically designed brochure for educating out-patients on the disease and healthy lifestyle was provided and explained in the third and fourth interview and were followed-up with question and answer session to ensure full-understanding. vs. Usual care

Length of the each intervention: 20-25 minutes

Number of intervention episodes: 5 times over  16 weeks


OutcomesPATIENTS

1) Blood Cholesterol level

2) Triglyceride level

3) % of patients with decrease in total cholesterol

4) % of patients with decrease in triglyceride level

5) Assessment of Quality of Life index using SF-36


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot explicitly described

Allocation concealment (selection bias)Unclear riskNot explicitly described

Baseline outcomes similar?Unclear riskSignificance for differences in baseline measurements for primary outcomes was not reported

Baseline characteristics similar?Unclear riskNot explicitly mentioned

Blinding (performance bias and detection bias)Low riskObjective outcomes

Protection against contamination?High riskRandomised by patient within one practice

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskOnly number of patients who completed the study given

Selective reporting (reporting bias)Unclear riskNot explicitly mentioned

Free from other bias?Low riskNone identified

Petkova 2008

MethodsRandomised controlled trial               

Unit of randomisation and analysis: patient


ParticipantsTen community pharmacies in Sofia, Bulgaria (upper-middle income country)

Patients registered as having asthma

patients - 50 ( 22 intervention group, 28 control group)

provider (delivering intervention) - One pharmacist and 10 pre-graduating pharmacists who had passed their exam in pharmaceutical care

practice - 10

no unit of analysis error


Interventionstargeted towards PATIENTS

Educational program on the disease, possible adverse drug reactions, recognition of early signs of exacerbation,  instruction on the appropriate use of medication, training in the inhaler technique,  the identification and control of asthma attacks, tobacco use and  efficacy of different methods on smoking cessation. Furthermore, educational leaflets were distributed after an educational session.

Length of each intervention: Not clear

Number of intervention episodes: 4 educational sessions over 4 months


OutcomesPATIENTS

1) Peak Expiratory Flow rate (L/min.) by using peak flow-meter

2) Quality of Life score: Patient’s quality of life was assessed though a disease-specific instrument Asthma specific form

(score: 1- “interference all of the time,” to 5-“interference none of the time”) which included 8 questions like duration and severity of disease, reasons for triggering asthma, application of inhaler during the past 4 weeks, availability of shortness of breath during past 4 weeks, frequency of hospitalisation and urgent medical aid calls (UMA) in the past 4 weeks and fully experienced day at work and at home in the past 4 weeks versus usual care

PROCESS

1) Hospitalisation rate

2) GP visits


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom numbers used

Allocation concealment (selection bias)Unclear riskreported that separation was based on the willingness to take part in the educational program

Baseline outcomes similar?Low riskPEF rate and QOL score was similar

Baseline characteristics similar?High riskMean age lower in intervention group as compared to control group and large differences in some variables

Blinding (performance bias and detection bias)Low riskObjective outcomes and GP visits and Hospitalisation were verified through medical records

Protection against contamination?High riskChance of contamination if patients of different groups were from the same family or if they were related.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComplete outcome data reported

Selective reporting (reporting bias)Low riskAll outcomes listed in method was reported in result

Free from other bias?Low riskNone identified

Petkova 2009

MethodsRandomised control trials

Unit of randomisation and analysis: patient


ParticipantsTwenty community pharmacy in Sofia, Bulgaria (upper middle income country)

Registered rheumatoid arthritis and osteoarthritis patients in the StIvan Rilski University Multiple profile Hospital.

patients- 90 ( 45 intervention group, 45 control group)

provider (delivering intervention) - One pharmacist and 5 pre-graduating pharmacists who had passed their exam in pharmaceutical care.

practice - 20

no unit of analysis error


Interventionstargeted towards PATIENTS

Educational program was delivered by pharmacists on:

a)      Information about disease, factor contributing in complications, how to differentiate the different kinds of arthritis, risk factors for development of arthritis.

b)      The correct application of “heat” and “cold” therapy.

c)      The importance of physical training and joint protection.

d)     Pain management, pharmacotherapy and possible adverse drug reactions (ADRs) during treatment. vs. Usual care

Length of each intervention: Not clear

Number of intervention episodes: 4 sessions over 4 month period


OutcomesPATIENTS

Patients’ subjective opinion of their quality of life were analysed by using Brief Pain Inventory which uses 0 to 10 scales with 0 being “no interference” and 10 being “complete interference” and was based on pain interference with various domains like general activity, mood, walking ability, normal work, relation with other people, sleep and  enjoyment of life.

PROCESS

Visits to GP

i. Not at all

ii. More than 6 times


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom numbers used

Allocation concealment (selection bias)Unclear riskNot explicitly described

Baseline outcomes similar?Low riskScore of arthritis interference in patients’ daily routine was found to be similar in both groups.

Baseline characteristics similar?High riskMean age lower in control group

Blinding (performance bias and detection bias)Low riskObjective outcomes (objective outcomes assessed; Brief Pain Index-validated pain assessment tool—assuming appropriately translated for Bulgarian population)

Protection against contamination?High riskSingle centre trial

Incomplete outcome data (attrition bias)
All outcomes
Low riskOne patient from intervention and two patients from controlled group ceased the study which might not affect the result

Selective reporting (reporting bias)Low riskOutcomes listed in method was reported in result

Free from other bias?Low riskNone identified

Sookaneknun 2004

MethodsRandomised controlled trial

Unit of randomisation and analysis : patient


ParticipantsOne university-affiliated community pharmacy in Mahasarakham and two primary care units in  in Takonyarng village and Kharmrieng village, Thailand (Lower-middle income country)

Hypertensive patients

patients- 235 ( 118 intervention group, 117 control group)

provider (delivering intervention) - a research pharmacist

practice-3

no unit of analysis error


Interventionstargeted towards PATIENTS

Pharmacist intervention consists of  counselling on the use of medications, identifying, resolving and preventing drug related problems (DRP) and monitoring of blood pressure. In addition, pharmacists provided education to patients on non-pharmacological approach of controlling the disease, like exercise, healthy diet, smoking, alcohol and weight reduction etc. Educational leaflets along with the diary to record lifestyle were also provided to the patients versus usual care

Length of each intervention: 30-50 minutes

Number of intervention episodes: every month over 6 months (6 times)


OutcomesPATIENTS

Blood Pressure

1) Systolic

2) Diastolic

3) % of patients controlled for systolic blood pressure and diastolic blood pressure


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot explicitly described

Allocation concealment (selection bias)Unclear riskNot explicitly described

Baseline outcomes similar?Low riskBaseline measurement of systolic and diastolic blood pressure was found to be equal in intervention and control group

Baseline characteristics similar?Low riskDemographic variables and disease was similar between two groups

Blinding (performance bias and detection bias)Low riskObjective outcomes

Protection against contamination?Unclear riskSingle centre trial

Incomplete outcome data (attrition bias)
All outcomes
Low riskIntention-to-treat analysis done although few patients dropped out from both intervention and control group

Selective reporting (reporting bias)Low riskOutcomes listed in methods were reported in results

Free from other bias?Low riskNone identified

Suppapitiporn 2005

MethodsRandomised controlled trial

Unit of randomisation and analysis: patient


ParticipantsOutpatient department of King Chulalongkorn Memorial Hospital, Thailand (lower middle income country)

Type-2 diabetes patients

patients - 360 (180 intervention group, 180 control group)

provider (delivering intervention) - 1

practice - 1

no unit of analysis error


Interventionstargeted towards PATIENT

4 intervention groups

Intervention1 (n=50): disease counselling and education by pharmacists + diabetes booklet + special medication containers

Intervention 2 (n=50): received counselling + special medication containers

Intervention 3 (n=30): disease counselling and education

Intervention 4 (n=50): disease counselling + diabetes information booklet

versus usual care

Length of each intervention: Not clear

Number of intervention episodes: 3 interventions at 0, 3 and 6 months


OutcomesPATIENTS

1) Mean Fasting Plasma Glucose (FPG)

2) HbA1c


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot specified

Allocation concealment (selection bias)Unclear riskNot explicitly described

Baseline outcomes similar?Low riskFPG (mg %) and HbA1c (mg %) were similar between intervention and control groups

Baseline characteristics similar?Low riskDemographic variables and medical history were similar between the groups

Blinding (performance bias and detection bias)Low riskOutcome variables were objective and medical records were used to assess outcome

Protection against contamination?High riskSubjects recruited from the single hospital

Incomplete outcome data (attrition bias)
All outcomes
Low riskAppears that outcome data was collected on all patients enrolled

Selective reporting (reporting bias)Unclear riskOutcomes not listed in methods

Free from other bias?Low riskNone identified

Zwarenstein 2007

MethodsCluster randomised trial

Unit of randomisation and analysis: general practice


ParticipantsGeneral Practices, Mitchells Plain, Cape Town, South Africa (upper-middle income country)

43 general practices (21 intervention group, 22 control group)

318 asthmatic children

provider (delivering intervention) - 1

no unit of analysis error


Interventionstargeted towards HEALTH CARE PROFESSIONALS
pharmacist versus no intervention

Educational session for GPs which contained 8 key messages aimed at improving diagnosis, prescribing and follow-up care for children with diagnosis. The intervention was academic detailing and tools such as visual aids were used.

Length of each intervention: 30 minutes

Number of intervention episodes: 2 visits over 3 months


OutcomesPATIENT

Change in asthma symptoms score reported by parent or guardian based on the three attack frequency questions.  Question was weighed by 0 to 3 points depending on the frequency of attacks in last 12 months. Furthermore, 1 to 2 episodes equalled 1 point, 3 episodes equalled 2 points, and 4 or more equalled 3 points. The maximum score that could be attained was 9 and minimum was 0


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom numbers used

Allocation concealment (selection bias)Low riskUsed computer generator list

Baseline outcomes similar?Low riskSimilar asthma symptom score between intervention and control groups

Baseline characteristics similar?Low riskDemographic variables similar

Blinding (performance bias and detection bias)Low riskObjective outcomes assessed; Asthma Sx score - validated tool

Protection against contamination?Low riskCluster randomisation

Incomplete outcome data (attrition bias)
All outcomes
Low riskComplete outcome data reported

Selective reporting (reporting bias)Low riskAll outcomes listed in method was reported in result

Free from other bias?Low riskNone identified

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Abu 2009Intervention was not delivered by pharmacists.

Jordan (Lower middle income country)

Aguwa 2008Before and after uncontrolled study with only one point of measurement before as well as after the intervention.

Nigeria (Lower middle income country)

Agyepong 2002Intervention was delivered by multi-disciplinary team.

Ghana (Low income country)

Akoria 2008Intervention was not delivered by pharmacists.

 Nigeria (Lower middle income country)

Alam 2007Commentary

Nepal (Low income country)

Anderson 2004Study was conducted in USA.

 USA (High income country)

Angalakuditi 2003Before and after uncontrolled study with only one point of measurement before as well as after the intervention.

India (Lower middle income country)

Angunawela, 1991Intervention was delivered by multi-disciplinary team.

 Sri Lanka (Lower middle income country)

Aramwit 2003Interrupted time series analysis with three data points not clearly reported. Only mean of three points was reported in the result.

Thailand (Lower middle income country)

Armando 2001No comparison of pre and post measurements. Descriptive study of the intervention.

Argentina (Upper middle income country)

Armando 2005No comparison of pre and post measurements. Descriptive study of the intervention.

Argentina (Upper middle income country)

Awad 2006Intervention was not delivered by pharmacists.

Sudan (Lower middle income country)

Beaton 2004Study was conducted in USA.

 USA (High income country)

Birrell 2000Retrospective study.

Tanzania (Low income country)

Botha 1992Interrupted time series analysis with only one point of measurement before and two points of measurement after the intervention.

South Africa (Upper middle income country)

Brimkulov 2009Intervention was not delivered by pharmacists.

Kyrgyzstan (Low income country)

Castro-Rios 2008Intervention was not delivered by pharmacists.

 Mexico (Upper middle income country)

Chaikoolvatana 2006Both inpatients and outpatients were included as participants.

 Thailand (Lower middle income country)

Chaiyakunapruk 2006Cross-sectional study.

Thailand (Lower middle income country)

De Andrade 2009Outcome was patient satisfaction.

Brazil (Upper middle income country)

De Lyra 2008Before and after uncontrolled study with only one point of measurement before as well as after the intervention.

Brazil (Upper middle income country)

De Souza 2007Before and after uncontrolled study with only one point of measurement before as well as after the intervention.

Brazil (Upper middle income country)

Domecq 1991Before and after uncontrolled study with only one point of measurement before as well as after the intervention.

Chile (Upper middle income country)

Dowse 2001Outcomes were knowledge and drug adherence (not desired outcome).

South Africa (Upper middle income country)

Dowse 2005Patients were followed up for only a few days and outcome was knowledge (not desired outcome).

 South Africa (Upper middle income country)

Dubey 2006Commentary.

Nepal (Low income country)

Eltayeb 2005Profession of individual delivering the intervention was not clear.

Sudan (Lower middle income country)

Erhun 2005Retrospective control group.

 Nigeria (Lower middle income country)

Esmaily 2009Intervention delivered by multi-disciplinary team.

Iran (Lower middle income country)

Garjani 2009Intervention was not delivered by pharmacists.

Iran (Lower middle income country)

Gonzalez 1996aIntervention was not delivered by pharmacists.

Cuba (Upper middle income country)

Greenberg 2005Intervention was not delivered by pharmacists.

Russia (Upper middle income country)

Gupta 2005Intervention was delivered by multidisciplinary team.

India (Lower middle income country)

Gutierrez 1994Intervention was not delivered by pharmacists.

Mexico (Upper middle income country)

Jing 2009Retrospective study.

Malaysia (Upper middle income country)

Lyra 2007Qualitative reporting of outcome

 Brazil (Upper middle income country)

Mao 2008Intervention was not delivered by pharmacists.

 China (Lower middle income country)

Me'emary 2009Intervention was not delivered by pharmacists.

Syrian Arab Republic (Lower middle income country)

Meyer 2001Intervention was not delivered by pharmacists.

 South Africa (Upper middle income country)

Mohagheghi 2005Intervention was not delivered by pharmacists.

Iran (Lower middle income country)

Nascimento 2009Observational, longitudinal, non-concurrent study.

Brazil (Upper middle income country)

Ngoh 1997Pharmacist intervention was for basic short counselling.

Cameroon (Lower middle income country)

Odusanya 2004Profession of individual delivering the intervention was not clear.

Nigeria (Lowermiddle income country)

Ofori-Adjei 1996Intervention was not delivered by pharmacists.

Ghana (Low income country)

Oparah 2006Before and after uncontrolled study with only one point of measurement before and after the intervention.

Nigeria (Lower middle income country)

Osiri 2001Cross-sectional study

Thailand (Lower middle income country)

Pankonin 2008Cross-sectional study

 Vietnam (Low income country)

Park 2007Intervention was delivered by multi-disciplinary team.

Korea, Republic (High income country)

Perera 1988Cross-sectional study

Sri Lanka (Lower middle income country)

Perez 2003Hospital-based intervention

 Colombia (Upper middle income country)

Perez-Cuevas 1996Intervention was not delivered by pharmacists

 Mexico (Upper middle income country)

Petkova 2005Interrupted time series analysis with only one point of measurement before and three points of measurement after the intervention.

Bulgaria (Upper middle income country)

Petkova 2006Interrupted time series analysis with only one point of measurement before and three points of measurement after the intervention.

Bulgaria (Upper middle income country)

Ratanajamit 2009Hospital-based intervention.

Thailand (Lower middle income country)

Rivera 2006Before and after uncontrolled study with only one point of measurement before and after the intervention.

Mexico (Upper middle income country)

Rosen 1978Study conducted in USA.

 USA (High income country)

Rosen 1978aStudy conducted in USA.

USA (High income country)

Santos 2006No comparison of pre and post measurements. 

Brazil (Upper middle income country)

Santoso 1996Intervention was not delivered by pharmacists

Indonesia (Lower middle income country)

Suryaprakasha 1983Commentary

India (Lower middle income country)

Turnacilar 2009Interrupted time series analysis with only one point of measurement before and six points of measurement after the intervention

Turkey (Upper middle income country)

Udomthavornsuk 1991Intervention was not delivered by pharmacists.

 Thailand (Lower middle income country)

Wood 2008Commentary

South Africa (Upper middle income country)

 
Characteristics of studies awaiting assessment [ordered by study ID]
Adisa 2012

MethodsRandomised controlled trial

ParticipantsDiabetic patients (Nigeria)

InterventionsPharmacist based educational, behavioural and motivational intervention

OutcomesFasting plasma glucose level and medication adherence

Notes

AJP 2011

MethodsNot known

ParticipantsNot known

InterventionsNot known

OutcomesNot known

NotesAbstract is not available.

Azzopardi 2010

MethodsRandomised controlled trial

ParticipantsRheumatoid arthritis patients on methotrexate

InterventionsClinical pharmacist intervention

OutcomesQuality of life using SF-36 questionnaire

NotesCountry where the study was conducted is not clear

Correr 2011

MethodsNon-randomised controlled trial (NRCT)

ParticipantsType 2 diabetic patients (Brazil)

InterventionsPharmacotherapy follow-up (PF) on metabolic control and clinical outcomes in type 2 diabetic patients.

OutcomesGlycosylated Haemoglobin A1 (HbA1) and fasting capillary glycaemia.

Notes

Costa 2012

MethodsProspective controlled study

ParticipantsHIV positive patients (Brazil)

InterventionsPharmacotherapeutic follow-up (PFU)

OutcomesCD4 count

NotesType of study is not clear

Dewulf 2011

MethodsInterventional study

ParticipantsPatients with inflammatory bowel disease at hospital (Brazil)

InterventionsPharmaceutical care program

OutcomesQuality of life (QOL) and disease clinical activity indexes (CAI)

NotesType of study is not clear

Dewulf 2012

MethodsRandomised controlled trial

ParticipantsPatients with inflammatory bowel disease at outpatient department (Brazil)

InterventionsPharmaceutical care program

OutcomesCompliance to medicine therapy (CMT), patient knowledge on drugs used (KDU), quality of life (QOL) and disease clinical activity indexes (CAI)

Notes

Fahimi 2011

MethodsRandomised controlled trial

ParticipantsPatients on warfarin therapy

InterventionsPharmacist-based warfarin-monitoring service

OutcomesControl of international normalized ratio (INR) within the therapeutic range

Notes

Farsaei 2011

MethodsRandomised Controlled Trial

ParticipantsType 2 diabetic patients (Iran)

InterventionsClinical pharmacist-led patient education program for type 2 diabetic patients

OutcomesFasting blood glucose level and glycosylated haemoglobin

Notes

Fuchs 2010

MethodsRandomised controlled trial

ParticipantsHypertensive patients under drug treatment (Brazil)

InterventionsPharmacist care with home BP measuring device

OutcomesSystolic and diastolic blood pressure

Notes

Lavoie 2011

MethodsRandomised controlled trial

ParticipantsAsthmatic patients

InterventionsMotivational intervention

OutcomesInhaled corticosteroid (ICS) adherence

NotesCountry where the study was conducted is not clear

Lee 2012

MethodsProspective trial

ParticipantsHypertensive patients

InterventionsPharmacist counselling service regarding hypertension, lifestyle modification and drug compliance checking

OutcomesSystolic and diastolic blood pressure

NotesCountry where the study was conducted is not clear

Lores 2011

MethodsProspective and intervention study

ParticipantsCongestive heart failure patients

InterventionsPharmacotherapeutic monitoring by pharmacists

OutcomesDetection, prevention and resolution of adverse events

NotesOutcomes and type of study is not clear as the article is in Spanish

Magedanz 2012

MethodsBefore and after study

ParticipantsCardiac patients (Brazil)

InterventionsAntimicrobial stewardship program by Pharmacist

OutcomesConsumptions of antibiotics

Notes

Malaty 2011

MethodsRandomised controlled trial

ParticipantsNonpregnant females aged 18-80 years who had been prescribed with fluconazole

InterventionsPharmacist educational intervention on vulvovaginal candidiasis

OutcomesUtilisation of fluconazole

NotesCountry where the study was conducted is not clear

Maria 2012

MethodsNot known

ParticipantsPatients on Antiretroviral therapy

InterventionsPharmaceutical care program on adherence to Antiretroviral therapy

OutcomesAdherence rate

NotesCountry where the study was conducted is not clear

Mohammad 2011

MethodsNot known

ParticipantsPatients discharged from hospital

Interventions(1) Therapeutic drug monitoring, (2) resolution of medication discrepancies (3) medication
and adherence counselling, and (4) identification and prevention of adverse drug events (ADEs).

OutcomesResolving important medication-related problems and needs

NotesCountry where the study was conducted is not clear

Mori 2010

MethodsNot known

ParticipantsHypertensive patients (Brazil)

InterventionsEducational program aimed at improving hypertensive patients' compliance to treatment

OutcomesSerum levels of cholesterol and fractions of tryacylglicerol (TG), urine sodium and potassium, arterial pressure (AP), body mass index (BMI) and waist-hip ratio (WHR)

Notes

Moten 2010

MethodsControlled study

ParticipantsType 2 diabetic patients

InterventionsMedication therapy management (MTM) by pharmacists

OutcomesMedication therapy management activities and glycosylated haemoglobin level

NotesCountry where the study was conducted is not clear and the research is in progress.

Ola-Olorun 2012

MethodsRandomised controlled trial

ParticipantsHypertensive patients (Nigeria)

InterventionsShort message service (SMS) of mobile telephone to provide medicine information to patients with chronic illnesses

OutcomesAdherence to therapy

NotesOutcome is not clear

Olives 2012

MethodsRandomised controlled study

ParticipantsPatients discharged with outpatient antibiotics

InterventionsMultimodality discharge instructions

OutcomesAntibiotic compliance

NotesCountry where the study was conducted is not clear.

Pinelli 2012

MethodsNot known

ParticipantsRenal transplant recipients (RTR) with diabetes

InterventionsPharmacist-managed diabetes and cardiovascular risk reduction care

OutcomesMean change in haemoglobin A1c (A1c) and percentage of RTR who obtained therapeutic goals

NotesCountry where the study was conducted is not clear.

Saokaew 2012

MethodsNon randomised controlled study

ParticipantsPatients who had been receiving long-term warfarin therapy for at least 3 months (Thailand)

InterventionsPharmacist managed warfarin therapy

OutcomesTime in therapeutic range (TTR), both actual- and expanded-TTR, bleeding and thromboembolic complications, and physician’ acceptance of pharmacist suggestions.

Notes

Shapiro 2010

MethodsNot known

ParticipantsNot known

InterventionsNot known

OutcomesNot known

Notes

Tahaineh 2011

MethodsRandomised controlled study

ParticipantsDyslipidaemic patients (Jordan)

InterventionsClinical pharmacy services

OutcomesChange in low density lipoprotein cholesterol levels

Notes

Tse 2011

MethodsNot known

ParticipantsPatients with respiratory disorders

InterventionsClinical pharmacists consultation

OutcomesMedication compliance

NotesCountry where the study was conducted is not clear.

 
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

 
Analysis 1.1 Comparison 1 (c) Comparison of the delivery of patient targeted services by pharmacists versus usual care, Outcome 1 Outcomes.
Outcomes

StudyOutcomesPre-

Intervention

(intervention vs. control group)
Post-

Intervention

(intervention vs.control group)
Change

due to intervention

(intervention vs. control group)
Result-interval(ΔI-ΔC)SignificanceNotes

Abdelhamid 2008PATIENT

1) Peak expiratory flow rate
not reportednot reportednot reportednon-sig.**p>0.05*calculated from reported  data

**exact value not reported

Abdelhamid 2008PROCESS

1) Rate of hospitalisation
not reportednot reportednot reporteddecreased significantly in intervention group (p<0.05) while  non-significantly increased (p>0.05) in control groupp<0.05p-value for intervention   vs. control  at the end of study

Adepu 2007PATIENT

1) Blood Glucose level(BGL)

2) ADDQOL score
198.31 mg/dl vs 173.6 mg/dl

not reported
142 mg/dl vs 171 mg/dl

not reported
-56.31 vs -2.6

not reported
-53.71 mg/dl

Significant improvement in intervention group as compared to control group
p<0.01*

p<0.001*
exact value not reported

 

* statistically significant

Adepu 2007PROCESS

n/a

Arun 2008PATIENT

1) Fasting Plasma glucose level (mg/dl)

2) Over all Health related Quality of life (HRQoL)
140.04 (24.16) vs 134.38 (20.46)

11.70 vs. 11.87
115.1 vs 149.28

16.94 vs. 11.66
-24.94±12.54 vs.14.9±11.24

5.24 vs. -0.21
-39.84

 

5.45
p=0.0001*

 

not reported
*Statistically significant

‡not significant

calculated from reported data

Arun 2008PROCESS

n/a

Ebid 2006PATIENT

Patients with COPD

1) HRQOL

a.General Health

b.Unhealthy days (physically)

c. Unhealthy days (mentally)

d. Days of activity limitation

2. PEFR,% predicted

Asthmatic patients

1) HRQOL        a.   General Health

b. Unhealthy days (physically)

c. Unhealthy days (mentally)

d.  Days of activity limitation

2) PEFR,% predicted
a. not reported

b.not reported

c.not reported

d. not reported

2.51.2± 8.6 vs 50.3 ±8.5

a. not reported

b. not reported

c.not reported

d.not reported

2. not reported
a. 3.8±0.9 vs. 1.9±0.7

b. 4.8±1.0 vs.8.1±2.3

c. 5.1±1.0 vs. 7.5±2.3

d. 6.2±1.3 vs. 12.0±3.1

2. 56.2±19.4 vs. 50.3±18.1

a. 4.1±0.7 vs. 2.5±0.9

b. 3.6±0.8 vs. 7.7±2.3

c. 4.5±0.9 vs. 6.8±2.3

d. 4.3±0.8 vs. 10.2±3.7

2. 87.2±11.2 vs.70.8±13.2
a. not reported

b. not reported

c. not reported

d. not reported

2. 5.0 vs 0

a. not reported

b. not reported

c.not reported

d. not reported

 

2. not reported
a. not reported

b. not reported

c. not reported

d. not reported

2. 5.0

a. not reported

b. not reported

c. not reported

d. not reported

2. not reported
a. p*

b. p*

c. p*

d. p*

2. p

a. p*

b. p*

c. p*

d. p*

2. p*
*exact value not reported, however, significant improvement in the intervention group as compared to control group

Not significant

Ebid 2006PROCESS

Patients with COPD

1) Number of visits to PCs or OPCs

2) Number of ER visits and hospitalisation

3) Costs for patient with COPD

Asthmatic patients

1) Number of visits to PCs or OPCs

2) Number of ER visits and hospitalisation

3) Costs for patient with Asthma
1) not reported

2) not reported

3) not reported

1) not reported

2) not reported

3) not reported
1)1.8±0.4 vs. 3.9±0.9

2) 0.81±0.16 vs.1.9±0.68

3) 340±116 vs.902±342

1) 1.1±0.20 vs. 2.2±0.51

2) 0.34±0.10 vs. 0.73±0.27

3) 225±77 vs.491±177
1) not reported

2) not reported

3)not reported

1) not reported

2) not reported

3) not reported
1)not reported

2) not reported

3) not reported

1) not reported

2) not reported

3) not reported
1) p*

2) p*

3) p*

1) p*

2) p*

3) p*
*exact value not reported, however, significant improvement in the intervention group as compared to control group

Gonzalez-Martin 2003PATIENT

1) Paediatric asthma quality of life questionnaire (PAQLQ) score

1) emotion

2) activities

3) symptoms

2) Spirometric values

a.   FVC

b.   FEV1
1) 5.2±0.4 vs.

5.2±0.4

2) 3.8 ±0.3 vs.

4.0±0.3

3) 4.1±0.5 vs.

4.6±0.4

a. 3.08±0.97 vs. 2.66 ± 0.19

b. 2.41 ±0.76 vs. 2.34 ±0.22
1) 6.5 vs. 5.2‡

2) 6 vs. 4.1‡

3) 6 vs. 4.8‡

a. 3.13±1.14 vs. 2.85±0.29

b. 2.48±0.89 vs. 2.51±0.27
1) 1.3vs 0

2) 2.2 vs. 0.1

3) 1.9 vs. 0.2

a. 0.05 vs. 0.19

b. 0.07 vs. 0.17
1) 1.3
2) 2.1

3) 1.7

a. -.14

b. -.1
1) p<0.01

2) p<0.01

3) p<0.02

a. p=n.s*

b. p=n.s*
* exact p-value not provided
calculated from reported data
‡data extrapolated from a graph

Gonzalez-Martin 2003PROCESS

n/a

Lugo 2007PATIENT

1) Systolic- blood pressure (mmHg)

2) Diastolic- blood pressure (mmHg)

3) Percentage of patients in various categories of hypertension
1) 147 vs. 148

2) 89 (intervention group)

3) 45% in stage II, 42% in  stage I, 9% in pre-hypertension and 3% in normal (intervention group)
1) 128 vs. 154

2) 83 (intervention group)

3) 9% in stage II, 45% in stage I, 39% in pre-hypertension and 6% in normal (intervention
1) -19  vs. 6

2) -6 vs. 0 **

3) -36% in stage II, -3% in stage II, 30% in pre-hypertension and 3% in normal (intervention group)
1) -25

2) -6

3) not reported

 
1) p<0.05*

2) p<0.05*

3)p<0.0001*‡

 
‡p-value for change in intervention group over study period

*statistically significant

**no change in control group reported

exact value for control group is not reported

Lugo 2007PROCESS

n/a

Paulos 2005PATIENT

1) Blood Cholesterol level (mg/dl)

2)Triglyceride level (mg/dl)

3) %  of patients with decrease in total cholesterol

4) % of patients with decrease in triglyceride level.

5) QOL index
1) 205.1±44.7 vs. 203.2±40.6

2) 190.7±88.7 vs. 163.6±116.

3) not reported

4) not reported

5) not reported
1) 178.1±31.1 vs. 199.1±37.6

2) 140.3±47.6 vs. 193.2±108.0

3) 72.8 vs. 33.3

4) 77.3 vs. 27.8

5) not reported
1) -27.1±41.1 vs. -1.4±37.2

2)-50.5±80.3 vs. 29.6±118.5

3) not reported

4) not reported

5) not reported
1) -25.7

2) -80.1

3) not reported

4) not reported

5) Significant improvement in intervention as compared to control
1) p=0.0266*

2) p=0.0169*

3) not reported

4) not reported

5)p<0.002
*p-value for change in intervention group over study period

p-value for intervention   vs. control  at the end of study

Paulos 2005PROCESS

n/a

Petkova 2008PATIENT

1) PEF rate (L/min.)

2) QOL
1) 335.45±15.73 vs. 332.14±14.49

2) 3.55±1.33 vs. 3.39±0.68
1)338.64±12.55 vs. 333.57±14.00

2) 3.77±1.02

vs. 3.00±0.90
1) 3.19 vs. 1.43

2) 0.22 vs. -.39
1) 1.76

2) 0.61
1) p<0.05*

2) p<0.001

p=0.039‡
*p-value for intervention  vs. control at the end of study

-p-value for change in intervention over a study.

‡p-value for change in control over a study period

Petkova 2008PROCESS

1)Hospitalisation rate

2) Visit to G.P

i) <2-3 times

ii) >6 times
1) 36.4% vs. 85.7%

2)

i) 63.7% vs. 17.9%

ii) 9.1% vs.3.6%
1) 13.6% vs. 78.6%

2)

i)86.4% vs. 21.4%

ii) 4.5% vs. 3.6%
1) -22.8% vs. -7.1%

2)

i) 22.7 % vs. 3.5%

ii) -4.6% vs.0%
1) -15.7%

2)

i) 19.2%

ii) -4.6%
1) p=0.001*

2) p=0.018
*p-value for intervention  vs. control at the end of study

-p-value for change in intervention over a study

Petkova 2009PATIENT

Arthritis interference in patients’ daily routine.

Pain interference with

i)  General activity

ii) Mood

iii) Walking ability

iv) Normal Work

v) Relation with other people

vi) Sleep

vii) Enjoyment of life
i) 7.63±1.235 vs. 7.67±1.229

ii) 7.16±1.851 vs. 7.14±1.612

iii) 7.93±1.370 vs.8.00±1.272

iv) 6.81±2.228 vs. 6.51±2.120

v) 4.26±2.391 vs. 4.00±2.370

vi) 7.98±1.752 vs. 8.09±1.231

vii) 6.95±1.812 vs. 6.93±1.737
i) 7.47±1.316 vs. 7.63±1.134

ii) 6.95±1.690 vs. 7.09±1.630

iii) 7.72±1.368 vs.7.88±1.258

iv) 6.67±2.212 vs. 6.56±1.980

v) 4.14±2.210 vs. 3.74±2.183

vi) 7.79±1.390 vs. 8.02±1.282

vii) 6.58±1.803 vs. 7.09±1.90

 
i) -0.16 vs. -0.04*

ii) -0.21 vs. -0.05*

iii) -0.21 vs. -0.12*

iv) -0.14 vs. 0.05*

v) -0.12 vs. -0.26*

vi) -0.19 vs.-0.07*

vii) -0.37 vs. 0.16*

 
i) -0.12

ii)-0.16

iii) -0.09

iv) -0.19

v) 0.14

vi) -0.12

vii) -0.53

 
i) p <0.05 ‡

ii) p <0.05 ‡

iii) p <0.05 ‡

iv) p <0.05 ‡

v) p <0.05‡

vi)p <0.05‡

vii) p <0.05‡
*calculated from the reported data.

‡p value for change in intervention group over a study period.

Petkova 2009PROCESS

Visits to GP

i) Not at all

ii)More than six times
i) 7% vs. 7%

ii) 23.3% vs. 18.6%
i) 18.6% vs.2.3%

ii)9.3% vs.18.6%
i)11.6% vs.-4.7%

ii) -14% vs.0%
i) 16.3%

ii)-14%
p=0.003‡

p<0.05‡
‡p value for change in intervention group over a study period.

Sookaneknun 2004PATIENT

1) Systolic blood pressure (mmHg)

2) Diastolic blood pressure

(mmHg)

3)% of patients controlled for systolic blood pressure and diastolic blood pressure
1) 144.76±19.69 vs. 142.41±19.81

2) 85.72±13.56vs
85.86±12.94

3) 22.88 vs. 17.94
1)121.47±14.90 vs.
124.77±17.97

2) 71.55±10.80  vs.
74.23±11.87

3) 66.10 vs.57.26
1) -23.29 ±19.10 vs. -18.64±17.67 *

2) -14.18 vs. -11.73*

3) 43.22 vs. 39.32 *
1) -4.56

2) -2.45

3) 3.9
1) p<0.001

2) p<0.001

3) p =0.061
*calculated from reported data

Sookaneknun 2004PROCESS

n/a

Suppapitiporn 2005PATIENT

a. All Intervention group vs. Control group

1) FPG (mg %)

2) HbA1c (mg%)

b.Intervention1  vs. Control

 1) FPG (mg %)

2) HbA1c (mg %)

c.Intervention 2 vs. Control

1) FPG (mg %)

2) HbA1c (mg %)

d. Intervention 3 vs. Control group

1) FPG (mg %)

2) HbA1c (mg %)

e. Intervention 4 vs. Control

1) FPG (mg %)

2) HbA1c (mg %)                
a.

1) 152.36±39.73 vs. 150.16±41.78

2) 8.16±1.44 vs. 8.01±1.51

b.

1) 147.46±36.07 vs. 150.16±41.78

2) 8.20±1.07 vs. 8.01±1.51

c.

1)139.78±33.15 vs.150.16±41.78   

2) 7.92±1.40 vs. 8.01±1.51   

d.

1) 168.60±39.30 vs. 150.16±41.78

2) 8.36±1.74 vs. 8.01 ±1.51

e.

1) 162.42±44.42 vs. 150.16±41.78

2) 8.07±1.53 vs. 8.01±1.51
a.

1) 145.20±46.0 vs. 159.16±54.90

2) 7.91±1.27 vs. 8.80±1.36

b.

1)130.21±33.96 vs.159.16±54.90

2) 7.91±1.11 vs. 8.80±1.36

c.

1) 141.21±45.8 vs. 159.16±54.90

2) 7.96±1.31 vs. 8.80±1.36

d.

1)158.34±57.81 vs. 159.16±54.90

2) 7.92±1.04 vs. 8.80±1.36

e.

1)160.98±50.39 vs. 159.16±54.90

2) 7.87±1.47 vs. 8.80±1.36
a.

1) -7.16 vs. 9

2) -0.25 vs. 0.79

b.

1) -17.25 vs. 9

2)-.29 vs. 0.79

c.

1) 1.43 vs. 9

2) 0.04 vs. 0.79

d.

1) -10.26 vs. 9

2) -0.44 vs. 0.79

e.

1) -1.44 vs. 9

2) -0.2 vs. 0.79
a.

1) -16.16

2) -1.04

b.

1) -26.25

2) -1.08

c.

1) -7.57

2) -0.75

d.

1) -19.26

2) -1.23

e.

1)-10.44

2) -.99

 
a.

1) p=0.013*

2) p<0.001*

b.

1) p=0.016*‡

2) p=0.001*‡

c.

1)n/a

2) p=0.005*‡

d.

1) not reported

2) not reported

e.

1) not reported

2) p=0.000*‡
*statistical significant difference

p-value for intervention vs. control at follow up

‡p-value for change in intervention group over a study.

Suppapitiporn 2005PROCESS

n/a
  

 
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

 
Analysis 2.1 Comparison 2 (c) Comparison of the delivery of health care professional-targeted services by pharmacists vs. usual care, Outcome 1 Outcome.
Outcome

StudyOutcomesPre-intervention (intervention vs. control)Post- intervention (intervention vs. control)Change due to intervention(intervention - control)Result Interval(ΔI-ΔC)SignificanceNotes

Zwarenstein 2007PATIENT

Asthma symptom score
7.71±0.11 vs. 7.48±0.093.63±0.26 vs. 4.24±0.27-4.08±0.23vs. -3.24±0.30-0.84p=0.03**statistically significant

Zwarenstein 2007PROCESS

n/a

 
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.

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

Patient or population: Pharmacies  or pharmacists delivering services in outpatient settings and asthmatic patients

Settings: South Africa (1)

Intervention:

Educational sessions to general practitioners (GPs) aimed at improving diagnosis, prescribing and follow-up care

Comparison: Usual services

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

Patient Outcome

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)
⊕⊕⊝⊝

low1

Health Service UtilisationNo Studies

CostNo Studies

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' due to imprecision and only one study included.
 
Table 1. Comparison between interventions (Analysis 1c)

Patient Outcomes (∆I - ∆C)Health Service utilisation (∆I - ∆C)Costs (∆I - ∆C)




InterventionBlood Glucose OutcomeBlood Pressure (BP) OutcomeBlood CholesterolAsthma/COPD outcomeArthritis OutcomeRate of HospitalisationGP VisitsMedication Cost

Counselling/ Patient EducationArun et al 2008

Fasting plasma glucose:

-39.84 mg/dl

 

Suppapitiporn et al 2005

Fasting Plasma Glucose (FPG) mg%: -19.26

HbA1c (mg %): -1.23
No studiesGonzalez et al 2003

PAQLQ score

emotion: 1.3

activities:2.1

symptoms: 1.7

Spirometric values

 FVC:  -.14‡

 FEV1: -.1‡
No studiesNo studiesNo studiesNo studies

Counselling/ Patient Education + BookletAdepu et al 2007

Random Blood Glucose level (BGL):

-53.71 mg/dl

QOL significantly improved in I group as compared to C group *

 

Suppapitiporn et al 2005

Fasting Plasma Glucose (FPG) mg%: -10.44

HbA1c (mg %): -.99
No studiesNo studiesPetkova et al 2008

PEF (l/min.): 1.76

QOL: 0.61
Petkova et al 2009

Small but statistically significant improvement in QOL (Arthritis interference in patient’s daily routine) in I group as compared to C group*
Petkova et al 2008

<2-3 times: 19.2%

>6 times: -4.6%
Petkova et al 2008

-15.7%
No studies

Counselling + Drug Review

 
No studiesNo studiesNo studiesAbdeilhamid et al 2008

non-significant improvement in Peak Expiratory Flow rate*
No studiesAbdeilhamid et al 2008

decreased significantly in intervention group (P<0.05) while  non-significantly increased (P>0.05) in control group
No studiesNo studies

Pharmaceutical care plan with scheduled follow-up +Patient education +BookletNo studiesLugo de Ortellado et al 2007

Systolic BP: -25 mmHg

Diastolic BP: --6mmHg

Sookaneknun et al 2004

Systolic BP: -4.56 mmHg

Diastolic BP:

 -2.45 mmHg
Paulos et al 2005

Blood Cholesterol

: -25.7 mg/dl

Blood Triglyceride

Systolic BP

: -80.1 mg/dl

QOL: significant improvement*
Ebid et al 2006

HRQOL: Significant improvement in I group as compared to C group for both patients of asthma and COPD*
No studiesEbid et al 2006

Number of ER visits and hospitalisation for both patients of asthma and COPD:

Significantly decreased in I group as compared to C group*

 
Ebid et al 2006

Number of visits to PCs or OPCs: Significantly decreased in I group as compared to C group  for both patients of asthma and COPD*
Ebid et al 2006

Significantly reduced in I group as compared to C group  for both patients of asthma and COPD*

Counselling +  Booklet+ Special medication containerSuppapitiporn et al 2005

Fasting Plasma Glucose (FPG) mg%: -26.25

HbA1c (mg %): -1.08
No studiesNo studiesNo studiesNo studiesNo studiesNo studiesNo studies

Counselling + Special medication containerSuppapitiporn et al 2005

Fasting Plasma Glucose (FPG) mg%: -7.57

HbA1c (mg%): -0.75
No studiesNo studiesNo studiesNo studiesNo studiesNo studiesNo studies

NotesI = Intervention                  (∆I - ∆C): Change due to intervention (intervention versus control group)

C = Control                          * Exact value not reported     Significant     ‡ Not significant

QOL: Quality of Life

 
Table 2. Comaprison between interventions (Analysis 2c)

Patient Outcomes (∆I - ∆C)Health Service utilisation (∆I - ∆C)Costs (∆I - ∆C




InterventionBlood Glucose OutcomeBlood Pressure (BP) OutcomeBlood CholesterolAsthma/COPD outcomeArthritis OutcomeRate of HospitalisationGP Visits

Academic detailing to GP + visual aidsNo studiesNo studiesNo studiesZwarenstein et al 2007

Asthma symptom score: -0.85
No studiesNo studiesNo studiesNo studies

NotesI = Intervention                  (∆I - ∆C): Change due to intervention (intervention versus control group)

C = Control                          * Exact value not reported     Significant     ‡ Not significant