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Greer N, Bolduc J, Geurkink E, et al. Pharmacist-Led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared to Usual Care [Internet]. Washington (DC): Department of Veterans Affairs (US); 2015 Oct.

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Pharmacist-Led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared to Usual Care [Internet].

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INTRODUCTION

Increased involvement of clinical pharmacists in patient care may offer increased access to primary care services and improved health care for patients.1,2 Recently introduced bills H.R. 592 and S. 314, the Pharmacy and Medically Underserved Areas Enhancement Act, are aimed to improve patient access to health care through pharmacists' patient care services. The bills would help officially establish pharmacists as health care providers and enable coverage of pharmacists' services through Medicare Part B in medically underserved communities.

Furthermore, pharmacist involvement in patient care may help to reduce inappropriate medication use, specifically in the elderly. A study in 2007 revealed that more than 85% of Veterans over the age of 65 who received care in VA outpatient facilities were given a potentially inappropriate medication.3 Inappropriate prescriptions cost the United States billions of dollars in healthcare expenditures annually and can result in increased morbidity, adverse drug events, hospitalization, and mortality.4,5 A study in Canada saw the proportion of patients receiving an inappropriate medication drop significantly after medication review and optimization by a team that included a pharmacist.6

Hepler and Strand defined pharmaceutical care as pharmacist collaboration with health team members to optimize therapeutic outcomes by identifying, solving, and preventing actual and potential drug therapy problems.7 Since 1995, the Department of Veterans Affairs has allowed Clinical Pharmacy Specialists (CPS) an expanded scope of practice with independent prescribing privileges.8 In this capacity, CPS have been detailed to perform “pharmaceutical care” or comprehensive medication management along with disease state management services in addition to less complex services such as patient medication counseling or responding to drug information questions. In the VA primary care setting, CPS are likely to be responsible for therapeutic outcomes for a multitude of conditions for any patient referred to CPS or proactively identified by CPS as a high-risk patient.

A 2014 systematic review of outpatient medication therapy management (MTM) interventions addressed 5 areas: 1) intervention components and features, 2) effectiveness in comparison to usual care, 3) factors under which outpatient-based MTM is effective and optimally delivered, 4) types of patients likely to benefit, and 5) types of patients at risk of harms from such programs.9 The review did not address MTM services provided by pharmacists shortly after hospital discharge, independent disease management services, or single episode contact. Interventions needed, at minimum, 3 elements to satisfy the inclusion criteria for the systematic review: comprehensive medication review, patient-directed education and counseling, and coordination of care, including prescriber-directed interventions. The MTM intervention criteria for the review were broader than the Medicare Part D MTM-defined interventions. Outpatient settings included long-term care settings, pharmacy call centers, and retail pharmacies. The review included interventions conducted in non-U.S. countries but published in English. Evidence was insufficient for many patient-centered outcomes of interest; however, MTM interventions improved medication appropriateness, adherence, and percentage of patients achieving a threshold adherence level while medication dosing was reduced. For some patient conditions, MTM interventions were associated with lowered odds of hospitalization and lower hospitalization costs. There was no observed benefit of MTM for patient satisfaction.

The purpose of this review is to identify the effectiveness and harms of pharmacist-led chronic disease management for community-dwelling adults with chronic diseases. Chronic disease management is a type of care that can be provided by pharmacists and aims to control symptoms and slow or stop disease progression. Chronic disease management is a multi-component intervention. We categorized intervention components as medication monitoring, medication therapy review, patient medication education, immunizations, disease self-care and support, and/or prescribing authority as detailed in Figure 1.

Figure 1. Components of Pharmacist-Led Chronic Disease Management.

Figure 1

Components of Pharmacist-Led Chronic Disease Management.

SCOPE OF REVIEW

This review focused on chronic disease management for outpatients in health care facilities excluding retail pharmacies. We emphasized patient- or health system-centered outcomes but also addressed intermediate measures including achievement of recommended therapeutic goals. Due to differences in pharmacy practices in other countries, this review was limited to U.S. studies.

We address the following key question developed with input from the topic nominator and a technical expert panel (TEP). The scope of the review is also depicted in an analytic framework (Figure 2).

Figure 2. Analytic Framework.

Figure 2

Analytic Framework.

Key Question: What are the effectiveness and harms of pharmacist-led chronic disease management compared to usual care?

Population: Adults (age 18 or older)

Interventions: Chronic disease management; pharmacist takes responsibility for some component of the management or prevention of one or more chronic diseases (eg, chronic obstructive pulmonary disease [COPD], congestive heart failure [CHF], diabetes, hypertension, cancer, chronic kidney disease [CKD], pain, depression) (ie, pharmacist-led care)

Comparator: Usual care without the services provided by the pharmacists to the intervention group

Outcomes:

  • Clinical Outcomes (including intermediate clinical measures): disease specific clinical events (ie, severe hypoglycemia or hypotension requiring additional interventions), depression, mortality, health related quality of life, patient satisfaction, disease specific intermediate goal attainment such as glycated hemoglobin [HbA1c], blood pressure, and lipid levels
  • Resource Use: office visits, urgent care or emergency room visits, hospitalizations, access to care, and costs
  • Medications: appropriate medications and dosages, drug interactions, (non)adherence, other

Timing: No minimum follow-up required

Setting: Interventions that take place within the United States and are provided to outpatients by pharmacists based in healthcare facilities

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