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Pharmacist-Led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared With Usual CarePharmacist-Led Chronic Disease Management

Nancy Greer, PhD; Jennifer Bolduc, PharmD; Eric Geurkink, PharmD; Thomas Rector, PhD, PharmD; Kimberly Olson, MD; Eva Koeller, BA; Roderick MacDonald, MS; and Timothy J. Wilt, MD, MPH
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 26 April 2016.


From the Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, and the University of Minnesota, Minneapolis, Minnesota.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government.

Grant Support: By the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative (#09-009).

Disclosures: Dr. Greer reports grants from the Department of Veterans Affairs during the conduct of the study. Dr. Rector reports grants from the Department of Veterans Affairs during the conduct of the study. Dr. Olson reports grants from the Department of Veterans Affairs during the conduct of the study. Ms. Koeller reports grants from the Department of Veterans Affairs during the conduct of the study. Mr. MacDonald reports grants from the Department of Veterans Affairs during the conduct of the study. Dr. Wilt reports grants from the Department of Veterans Affairs during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-3058.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.

Reproducible Research Statement:Study protocol: Available in the Supplement. Statistical code: RevMan 5.3; DerSimonian–Laird random-effects model. Data set: Available in the full report (www.hsrd.research.va.gov/publications/esp).

Requests for Single Reprints: Nancy Greer, PhD, Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center (111-O), Minneapolis, MN 55417; e-mail, nancy.greer@va.gov.

Current Author Addresses: Drs. Greer, Bolduc, Geurkink, Rector, Olson, and Wilt; Ms. Koeller; and Mr. MacDonald: Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN 55417.

Author Contributions: Conception and design: N. Greer, J. Bolduc, E. Geurkink, K. Olson, E. Koeller, T.J. Wilt.

Analysis and interpretation of the data: N. Greer, J. Bolduc, E. Geurkink, T. Rector, K. Olson, E. Koeller, R. MacDonald, T.J. Wilt.

Drafting of the article: N. Greer, J. Bolduc, E. Geurkink, E. Koeller, R. MacDonald, T.J. Wilt.

Critical revision of the article for important intellectual content: N. Greer, E. Geurkink, J. Bolduc, T. Rector, E. Koeller, T.J. Wilt.

Final approval of the article: N. Greer, J. Bolduc, E. Geurkink, T. Rector, K. Olson, E. Koeller, R. MacDonald, T.J. Wilt.

Provision of study materials or patients: N. Greer.

Statistical expertise: T. Rector, R. MacDonald, T.J. Wilt.

Obtaining of funding: T.J. Wilt.

Administrative, technical, or logistic support: N. Greer, E. Koeller, T.J. Wilt.

Collection and assembly of data: N. Greer, J. Bolduc, T. Rector, K. Olson, E. Koeller, R. MacDonald.


Ann Intern Med. 2016;165(1):30-40. doi:10.7326/M15-3058
Text Size: A A A

Background: Increased involvement of pharmacists in patient care may increase access to health care and improve patient outcomes.

Purpose: To determine the effectiveness and harms of pharmacist-led chronic disease management for community-dwelling adults.

Data Sources: MEDLINE, Cochrane Library, CINAHL, and International Pharmaceutical Abstracts from 1995 through February 2016, and reference lists of systematic reviews and included studies.

Study Selection: 65 patient populations in 63 studies conducted in the United States of any design reported outcomes of pharmacist-led chronic disease management versus a comparator for community-dwelling adults in the United States. Studies set in retail pharmacies were excluded.

Data Extraction: Data extraction done by a single investigator was confirmed by a second investigator; risk of bias was assessed by 2 investigators; and strength of evidence was determined by consensus.

Data Synthesis: Pharmacist-led care was associated with similar numbers of office visits, urgent care or emergency department visits, and hospitalizations (moderate-strength evidence) and medication adherence (low-strength evidence) compared with usual care (typically continuing a prestudy visit schedule). Pharmacist-led care increased the number or dose of medications received and improved study-selected glycemic, blood pressure, and lipid goal attainment (moderate-strength evidence). Mortality and clinical events were similar (low-strength evidence). Evidence on patient satisfaction was mixed and insufficient. The reporting of harms was limited.

Limitations: Interventions were heterogeneous. Studies were typically short-term and designed to assess physiologic intermediate outcomes rather than clinical events. Reporting of many clinical outcomes of interest was limited, and often they were not the study-defined primary end points.

Conclusion: Pharmacist-led chronic disease management was associated with effects similar to those of usual care for resource utilization and may improve physiologic goal attainment. Further research is needed to determine whether increased medication utilization and goal attainment improve clinical outcomes.

Primary Funding Source: Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative.

Figures

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Figure 1.

Components of pharmacist-led chronic disease management.

* Follow-up after prescription for medication effectiveness and safety and drug-related problems.

† Includes medication reconciliation.

‡ The pharmacist provides immunization, which was not an outcome of interest.

§ Facilitate access to other health care professionals and provide education about disease, lifestyle changes, aspirin therapy, and tobacco cessation.

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Appendix Figure.

Summary of evidence search and selection.

CCT = controlled clinical trial; IPA = International Pharmaceutical Abstracts; RCT = randomized, controlled trial.

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Figure 2.

Goal attainment for diabetes, dyslipidemia, hypertension, and polypharmacy studies, by primary outcome.

Risk ratios were calculated by using Mantel–Haenszel random-effects models. BP = blood pressure, HbA1c = hemoglobin A1c; LDL-C = low-density lipoprotein cholesterol.

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