Reviewing the evidence

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AJP looks closely at some of the statements in the recent JPPR debate between GP Dr Evan Ackermann and consultant clinical pharmacist Debbie Rigby

This week we covered a new debate section in the Journal of Pharmacy Practice and Research, in which GP Dr Evan Ackermann argues in his ‘case against’ expanded primary care services in pharmacies.

Arguing the ‘case for’ pharmacists to adopt expanded roles in primary care, consultant clinical pharmacist Debbie Rigby writes that innovative and expanded roles for pharmacists can add value to the primary healthcare outcomes for consumers.

But what research did they actually base their opinions on? We look at the evidence behind the arguments.

Expanded roles for community pharmacists

What Dr Evan Ackermann said: “High quality systematic reviews have failed to unequivocally support the clinical value of medication review or management interventions by community pharmacists.

“At best, there are minor improvements in surrogate markers (e.g. HbA1c, blood pressure, lipids) and minor medication error detection.

“The reality is, current pharmacy medication management interventions do not reliably result in significant clinical benefit.

“There is now a considerable body of high-level evidence supporting limited or no health benefit from expanded community pharmacist roles.”

His evidence:

Viswanathan M, Kahwati LC, Golin CE, Blalock SJ, CokerSchwimmer E, Posey R, et al. Medication therapy management interventions in outpatient settings: a systematic review and metaanalysis. JAMA Intern Med 2015; 175: 76–87

  • This systematic review and meta-analysis of 44 studies found that evidence was insufficient to determine the effect of medication therapy management (MTM) interventions on most evaluated outcomes (e.g., drug therapy problems, adverse drug events, disease-specific morbidity, disease-specific or all-cause mortality, and harms).
  • However it found MTM interventions improved medication appropriateness (4.9 vs 0.9 points on the medication appropriateness index, P < .001), adherence (approximately 4.6%), and percentage of patients achieving a threshold adherence level (odds ratios [ORs] ranged from 0.99 to 5.98) and reduced medication dosing (mean difference, -2.2 doses; 95% CI, -3.738 to -0.662).
  • Medication therapy management interventions reduced health plan expenditures on medication costs, although the studies reported wide CIs. For patients with diabetes mellitus or heart failure, MTM interventions lowered the odds of hospitalization (diabetes: OR, 0.91 to 0.93 based on type of insurance; adjusted hazard rate for heart failure: 0.55; 95% CI, 0.39 to 0.77) and hospitalization costs (mean differences ranged from −$363.45 to −$398.98).
  • The interventions conferred no benefit for patient satisfaction and most measures of health-related quality of life (low strength).

Huiskes VJ, Burger DM, van den Ende CH, van den Bemt BJ. Effectiveness of medication review: a systematic review and meta-analysis of randomized controlled trials. BMC Fam Pract 2017; 18: 5.

  • In a systematic review of 31 RCTs (55% low risk of bias) exploring the effect of medication review as an isolated intervention without co-interventions during a short term (≤3 months) intervention period, an effect was found on most drug-related problems: medication review resulted in a decrease in the number of drug-related problems, more changes in medication, more drugs with dosage decrease and a greater decrease or smaller increase of the number of drugs.
  • However no effect of medication review was found on clinical outcomes (mortality, hospital admissions/healthcare use, the number of patients falling, physical and cognitive functioning).

Riordan DO, Walsh KA, Galvin R, Sinnott C, Kearney PM, Byrne S. The effect of pharmacist-led interventions in optimising prescribing in older adults in primary care: a systematic review. SAGE Open Med 2016; 4: 2050312116652568.

  • In this systematic review of five studies, four studies involved a pharmacist conducting a medication review and providing feedback to patients or their family physician. One randomised controlled trial evaluated the effect of a computerised tool that alerted pharmacists when elderly patients were newly prescribed potentially inappropriate medications. Four studies were associated with an improvement in prescribing appropriateness.
  • Three of the five studies reported an improvement in the Medication Appropriateness Index (MAI) score in the intervention group compared to the control group.
  • The authors concluded that their results demonstrated that pharmacist-led interventions may improve prescribing appropriateness in community-dwelling older adults. “However, it is unclear if these interventions result in clinically significant improvements in patient outcomes,” they said, calling for further investigation into pharmacists in primary care.

Kolhatkar A, Cheng L, Chan FK, Harrison M, Law MR. The impact of medication reviews by community pharmacists. J Am Pharm Assoc (2003) 2016;56:513–20. e1.

  • This interrupted time series set in British Columbia, Canada found that medication reviews did not significantly modify prescription drug use by recipients.
  • “For pharmacist recommendations to influence drug utilization, they have to influence physician prescribing; however, evidence suggests that such change is best achieved through direct interaction between the pharmacist and prescriber,” the authors suggest.
    “Existing literature, and our study, demonstrate that pharmacist-led interventions targeted at adults with poorly controlled disease states, such as diabetes or hypertension, are more effective than those programs targeted at adults or seniors in general.”

Jokanovic N, Tan EC, Sudhakaran S, Kirkpatrick CM, Dooley MJ, Ryan-Atwood TE, et al. Pharmacist-led medication review in community settings: an overview of systematic reviews. Res Social Adm Pharm 2017; 13: 661–85

  • Of the 35 relevant systematic reviews identified, 24 were of moderate and seven of high quality and were included in the data synthesis.
  • The largest overall numbers of unique primary research studies with favorable outcomes were for diabetes control (78% of studies reporting the outcome), blood pressure control (74%), cholesterol (63%), medication adherence (56%) and medication management (47%). Significant reductions in medication and/or healthcare costs were reported in 35% of primary research studies. Meta-analysis was performed in 12 systematic reviews. Results from the meta-analyses suggested positive impacts on glycosylated hemoglobin, blood pressure, cholesterol, and number and appropriateness of medications.
  • The authors concluded that: “Moderate and high quality systematic reviews support the value of pharmacist-led medication review for a range of clinical outcomes.”

What Debbie Rigby said: “Pharmacists’ services and involvement in patient care have been associated with improved health and economic outcomes, reduced adverse drug events, improved quality of life and reduced morbidity and death.

“Independent prescribing by pharmacists has been shown to be safe and clinically appropriate, and acceptable to patients.”

Her evidence:

Roughead L, Semple S, Vitry A. The value of pharmacist professional services in the community setting a systematic review of the literature 1990–2002. Adelaide: Quality use of Medicines and Pharmacy Research Centre, University of South Australia; 2003

  • This systematic review of evidence from 1990-2002, by researchers from the University of South Australia’s Quality Use of Medicines and Pharmacy Research Centre, included more than 70 randomised controlled trials that looked at professional pharmacist services.
  • The 200-page, in-depth analysis found that “there is clear evidence across a number of different settings for the effectiveness of pharmaceutical care services, continuity of care services post-hospital discharge, pharmacist education services to consumers and pharmacist education services to health practitioners for improving patient outcomes or medication use”.
  • The review was commissioned by the Pharmacy Guild of Australia through the Third Community Pharmacy Agreement Research and Development Grants Program.

Hatah E, Braund R, Tordoff J, Duffull SB. A systematic review and meta-analysis of pharmacist-led fee-for-services medication review. Br J Clin Pharmacol 2013; 77: 102–115

  • This systematic review and meta-analysis of 21 studies for primary outcomes and 32 for secondary outcomes found results favouring pharmacists’ intervention for blood pressure (OR 3.50, 95% CI 1.58, 7.75, P = 0.002) and low density lipoprotein (OR 2.35, 95% CI 1.17, 4.72, P = 0.02).
  • Outcomes on hospitalization (OR 0.69, 95% CI 0.39, 1.21, P = 0.19) and mortality (OR 1.50, 95% CI 0.65 to3.46, P = 0.34) indicated no differences between the groups.
  • On subgroup analysis, clinical medication review reduced hospitalization (OR 0.46, 95% CI 0.26, 0.83, P =0.01) but not adherence support review (OR 0.88, 95% CI 0.59, 1.32, P = 0.54).
  • The majority of the studies (57.9%) showed improvement in medication adherence. “Fee-for-service pharmacist-led medication reviews showed positive benefits on patient outcomes,” the authors concluded.

Latter S, Blenkinsopp A, Smith A, Chapman S, Tinelli M, Gerard K, et al. Evaluation of nurse and pharmacist independent prescribing. Final Report. Southampton, UK; Keele, UK: Department of Health Policy Research Programme, University of Southampton/Keele University; 2011.

Tsuyuki RT, Houle SK, Charrois TL, Kolber MR, Rosenthal MM, Lewanczuk R, et al. Randomized trial of the effect of pharmacist prescribing on improving blood pressure in the community: the Alberta Clinical Trial in Optimizing Hypertension (RxACTION). Circulation 2015; 132: 93–100.

  • In a patient-level, randomized, controlled trial, enrolling adults with above-target blood pressure (as defined by Canadian guidelines) through community pharmacies, hospitals, or primary care teams in 23 communities in Alberta, intervention group patients received an assessment of BP and cardiovascular risk, education on hypertension, prescribing of antihypertensive medications, laboratory monitoring, and monthly follow-up visits for 6 months (all by their pharmacist).
  • Results showed the intervention group had a mean±SE reduction in systolic BP at 6 months of 18.3±1.2 compared with 11.8±1.9 mm Hg in the control group, an adjusted difference of 6.6±1.9 mm Hg (P=0.0006).
  • The authors concluded that pharmacist prescribing for patients with hypertension resulted in a clinically important and statistically significant reduction in BP. Policy makers should consider an expanded role for pharmacists, including prescribing, to address the burden of hypertension.

Pharmacist vaccination

What Dr Evan Ackermann said: “A review of community pharmacy immunisation programs demonstrated that they added no value to routine immunisation programs and therefore may have little societal benefit.”

His evidence:

Perman S, Kwiatkowska RM, Gjini A. Do community pharmacists add value to routine immunization programmes? A review of the evidence from the UK. J Public Health (Oxf) 2018. 10.1093/pubmed/fdy021.

  • British researchers conducted a review of peer-reviewed studies and unpublished evaluations of community pharmacy-based vaccination services implemented in the UK between 2000 and 2015.
  • From identified 28 evaluations of pharmacy immunization programmes in the UK, only three of which were published in peer-reviewed journals. These showed no evidence of increased vaccination uptake, and weak evidence of widening access to individuals who had not previously been vaccinated. However they found “there was good evidence that pharmacies were acceptable and convenient venues for vaccination”.

What Debbie Rigby said: “Pharmacist involvement in immunisation, whether as educators, facilitators or administrators of vaccines, has resulted in increased uptake of immunisations compared with vaccine provision by traditional providers without pharmacist involvement.”

Her evidence:

Isenor JE, Edwards NT, Alia TA, Slayter KL, MacDougall DM, McNeil SA, et al. Impact of pharmacists as immunizers on vaccination rates: a systematic review and meta-analysis. Vaccine 2016;34:5708–23

  • Canadian researchers conducted a systematic review and meta-analysis on the topic of pharmacists and immunisation.
  • Thirty-six studies were included in the review: 22 assessed the role of pharmacists as educators and/or facilitators and 14 assessed their role as administrators of vaccines.
  • All studies reviewed found an increase in vaccine coverage when pharmacists were involved in the immunization process, regardless of role (educator, facilitator, administrator) or vaccine administered (e.g., influenza, pneumococcal), when compared to vaccine provision by traditional providers without pharmacist involvement.

What do you think of the evidence? Let us know in the comments section below.

Read Evan Ackermann’s opinion piece here

Read Debbie Rigby’s opinion piece here

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  1. Andrew

    Great work Sheshtyn, thanks for this.

  2. Nicholas Logan

    Dr Ackermann’s opinion is always hamstrung by perceived turf wars and commercial interests. Debbie Rigby’s motivation is positive health outcomes.

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