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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Impact of pharmacist care in the management of cardiovascular disease risk factors: a systematic review and meta-analysis of randomized trials

V Santschi, A Chiolero, B Burnand, AL Colosimo, and G Paradis.

Review published: 2011.

Link to full article: [Journal publisher]

CRD summary

This review found that pharmacist-directed care or care delivered in collaboration with doctors or nurses improved management of cardiovascular disease risk factors in outpatients. The authors' conclusions reflect the evidence presented, but potential publication bias and substantial heterogeneity for most outcomes should be borne in mind when interpreting the conclusions. Generalisability of the findings to UK settings is uncertain.

Authors' objectives

To determine the impact of pharmacist care on the management of cardiovascular disease risk factors in outpatients.

Searching

PubMed, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to November 2010. There were no language restrictions. Reference lists of relevant articles were searched for additional studies. Search terms were reported. A full search strategy was presented in an online appendix.

Study selection

Randomised controlled trials (RCTs) that evaluated care delivered by pharmacists to adult outpatients with modifiable cardiovascular disease risk factors were eligible for the review. Trials were included irrespective of whether patients were already receiving pharmacological treatment for cardiovascular disease. Interventions were delivered by pharmacists alone or in collaboration with doctors and/or nurses and included patient education, patient reminder systems, medication management, feedback to other health professionals and measurement of cardiovascular disease risk factors. Trials had to include a usual care group. Outcomes of interest were systolic and diastolic blood pressure, total cholesterol, low-density lipoprotein cholesterol (LDL-C) and smoking. Studies involving only patients with diabetes were excluded.

Mean age of participants in included trials ranged from 52 to 77 years; 54% were women. Risk factors varied. Many participants had controlled or uncontrolled dyslipidaemia or hypertension. Most trials were conducted in outpatient clinics or community pharmacies. Trial duration ranged from three to 24 months. The largest single source of trials was USA; none of the included trials were conducted in UK.

Two reviewers independently selected studies for the review. Disagreements were resolved by discussion.

Assessment of study quality

Validity was assessed by two reviewers independently using the Cochrane risk of bias tool. Disagreements were resolved by discussion.

Data extraction

Data were extracted to calculate relative risks (RRs) for dichotomous outcomes and mean differences for continuous outcomes, each with associated 95% confidence intervals (CIs). Standard deviations were calculated from standard errors or 95% confidence intervals presented in the articles where required.

Data were extracted independently by two reviewers. It appeared that discrepancies were resolved by discussion.

Methods of synthesis

Studies were pooled by meta-analysis using random-effects models. Heterogeneity was quantified using the I2 and Χ2. Sources of heterogeneity were explored in post hoc subgroup analyses. Several sensitivity analyses were performed (details reported in the paper). Publication bias was assessed using funnel plots and Egger's test.

Results of the review

Thirty RCTs with 11,765 participants were included. Methodological quality was variable: few trials reported on allocation concealment or blinding of outcome assessors, but most were free of selective outcome reporting.

Pharmacist care was associated with statistically significant reductions in systolic (weighted mean difference (WMD) -8.1mmHg, 95% CI -10.2 to -5.9; 19 trials) and diastolic (WMD -3.8mmHg, 95% CI -5.3 to -2.3; 19 trials) blood pressure, total cholesterol (WMD -17.4mg/L, 95% CI -25.5 to -9.2; nine trials) and LDL-C (WMD -13.4mg/L, 95% CI -23.0 to -3.8; seven trials) compared with usual care. There was a significant reduction in the risk of smoking in the pharmacist care group (RR 0.77, 95% CI 0.67 to 0.89; two trials). Substantial heterogeneity was present for all outcomes except smoking.

For blood pressure, no differences in effect were found between pharmacist-directed and pharmacist-collaborative interventions or most of the other subgroups that were examined. The only exception was that interventions that did not involve patient education did not significantly reduce diastolic blood pressure. Sensitivity analyses did not substantially alter the findings. Funnel plots and Egger tests indicated potential publication bias.

Authors' conclusions

Pharmacist-directed care or care delivered in collaboration with doctors or nurses improved management of major cardiovascular disease risk factors in outpatients

CRD commentary

The review question and inclusion criteria were clear. The authors searched a range of relevant sources. There were no language restrictions. Unpublished studies were not sought; publication bias was assessed using standard methods and a risk of publication bias was identified. Appropriate methods were used to minimise risks of errors or bias affecting the review process. Relevant details of included trials were presented. Trial quality was assessed and the results were used in the synthesis. Sources of heterogeneity in the meta-analyses were investigated using subgroup and sensitivity analyses.

This was a generally well-conducted review and the authors' conclusions reflect the evidence presented. However, the potential presence of publication bias and the substantial heterogeneity observed for most outcomes should be borne in mind when interpreting the conclusions. None of the included trials were done in UK, so the generalisability of the review to UK settings is uncertain.

Implications of the review for practice and research

Practice: The authors stated that in view of difficulties in accessing primary care physicians, the integration of pharmacists in the care of outpatients should be considered as a valuable solution for improving the management of cardiovascular disease risk factors.

Research: The authors stated that research was needed to identify which types of pharmacist interventions were most effective and on how pharmacist care could be enhanced in various health care systems.

Funding

Supported in part by the Canadian Institutes of Health Research Applied Public Health Research Chair in Chronic Disease Prevention.

Bibliographic details

Santschi V, Chiolero A, Burnand B, Colosimo AL, Paradis G. Impact of pharmacist care in the management of cardiovascular disease risk factors: a systematic review and meta-analysis of randomized trials. Archives of Internal Medicine 2011; 171(16): 1441-1453. [PubMed: 21911628]

Indexing Status

Subject indexing assigned by NLM

MeSH

Blood Pressure; Cardiovascular Diseases /epidemiology /prevention & control; Cholesterol /blood; Cholesterol, LDL /blood; Female; Humans; Male; Patient Education as Topic /statistics & numerical data; Pharmacists; Professional-Patient Relations; Randomized Controlled Trials as Topic; Risk Factors; Smoking /epidemiology; Treatment Outcome

AccessionNumber

12011005460

Database entry date

21/09/2011

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 21911628

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