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The role and impact of the pharmacist in long-term care settings: A systematic review
SCIENCE AND PRACTICE Journal of the American Pharmacists Association xxx (2019) 1e9
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REVIEW
The role and impact of the pharmacist in long-term care settings: A systematic review Cheryl A. Sadowski*, Theresa L. Charrois, Evan Sehn, Trish Chatterley, Sujin Kim a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 July 2019 Accepted 12 November 2019
Objective: Older adults in long-term care (LTC) are often frail and comorbid and have multiple medications. Although medication review by pharmacists has been integrated into LTC practice in many countries through policy and reimbursement models, the impact is variable in the literature. The purpose of our study was to review the literature regarding the impact of the pharmacist in LTC. Data sources: Four databases were searched from inception to September 2017, including Ovid MEDLINE, Ovid Embase, Ovid Evidence-Based Medicine Reviews (Cochrane Library), and Ovid International Pharmaceutical Abstracts. Study selection: Studies in any language were included if they met the following criteria: (1) pharmacist involved in care, (2) quasi-experimental or experimental design, and (3) conducted in LTC. Data extraction: Two reviewers independently reviewed the titles, abstracts, and full-text articles to determine if they met inclusion criteria, with a third researcher resolving discrepancies. Data of included studies were independently abstracted by 2 reviewers and confirmed by a third researcher. Results: Twenty-six studies (total N ¼ 20,228, median study duration ¼ 12 months) met the inclusion criteria. Medication review was the most common intervention, evaluated in 24 studies (92%). Eleven studies (42%) reported on the total number of medications per patient, with 7 studies finding a statistically significant reduction in medication usage. Six studies focused on psychotropic medications, with 4 of those leading to a reduction in medication. Explicit medication appropriateness criteria showed improvement in 5 studies. Medication and health care costs were evaluated in 14 studies (54%), with 4 reporting a statistically significant reduction. Studies reporting hospitalizations (10, 38%) were moderately heterogeneous (I2 ¼ 59%) and failed to demonstrate an impact. Studies reporting mortality (8, 31%) were less heterogeneous (I2 ¼ 0%), but they also failed to show a change. Conclusion: There is evidence to support pharmacist intervention, primarily through medication review, to improve measures in medication appropriateness. © 2019 Published by Elsevier Inc. on behalf of the American Pharmacists Association.
Introduction In 2015, 2.6% of seniors older than 65 years in the United States resided in nursing homes, although this dramatically increased to 9.5% of those aged 85 years and older.1 This
compares to 4.5% of seniors worldwide living in long-term care (LTC) facilities.2 This group of seniors is usually characterized by frailty, multimorbidity, and polypharmacy.3-6 With increased polypharmacy comes increased medication regimen complexity (MRC).7 There is an association
Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Funding: This work was supported by the Faculty of Pharmacy & Pharmaceutical Sciences Katz Endowment Fund, University of Alberta. The funder played no role in the design, execution, analysis, interpretation, or writing of this work. * Correspondence: Cheryl A. Sadowski, BSc(Pharm), PharmD, BCGP, FCSHP, Professor, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, AB T6G 1C9, Canada. E-mail address: [email protected] (C.A. Sadowski). https://doi.org/10.1016/j.japh.2019.11.014 1544-3191/© 2019 Published by Elsevier Inc. on behalf of the American Pharmacists Association.
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Methods Key Points Search strategy and selection criteria Background: Almost 5% of older adults worldwide are in longterm care facilities, and most of these individuals are frail and have polypharmacy. There is evidence that pharmacists improve disease focused outcomes in the outpatient and hospital settings, but the evidence supporting the effect of pharmacists in a multimorbid frail population in long-term care is uncertain. Findings: There are a number of studies conducted internationally on the pharmacist role in long-term care, but most studies are not randomized and have high risk of bias. Pharmacists in long-term care improve medication outcomes by increasing appropriateness, reducing the number of medications, and in particular, reducing psychotropics. Interventions by pharmacists in long-term care lead to reduced medication costs, but not reduced hospitalizations or mortality.
between increased MRC and an increase in adverse drug events (ADEs) and emergency department (ED) visits.7 Pharmacists’ skill sets and scope of practice put them in a position to help reduce MRC, prevent ADE and ED visits, and reduce health care expenditures. In several countries, the roles and responsibilities of pharmacists have expanded. Various forms of independent or collaborative pharmacist prescribing have been implemented in the United States, United Kingdom, New Zealand, and Canada.8-11 In the United States, United Kingdom, Ireland, Portugal, and Canada, pharmacists are authorized to administer injections.10-14 Pharmacists are also becoming increasingly more involved in the provision of primary care and chronic disease management.15,16 Remuneration models to help pay for these clinical pharmacy services have been implemented in several countries including the United States, United Kingdom, Australia, New Zealand, and Canada.17 Recent Canadian studies have clearly demonstrated the positive impact expanded pharmacy practice has on the control of patients with hypertension or dyslipidemia.18,19 It is hypothesized that seniors living in LTC could also reap the benefits that expanded pharmacy services can provide. However, despite the push for pharmacists to take on more clinical roles, few studies have analyzed the impact of pharmacist interventions on seniors living in LTC. Therefore, the objective of this review is to evaluate the effect of pharmacist-based interventions on medication, health system, and clinical outcomes in seniors living in LTC. Specifically, we attempted to determine if LTC settings that involve a pharmacist, compared with no pharmacist involvement, have improved medication, clinical, or health system outcomes using randomized or quasi-experimental studies.
2
For this systematic review, the Preferred Reporting Items for Systematic Reviews and Meta-analyses recommendations were followed. With the assistance of a medical librarian (TC), a comprehensive literature search of Ovid MEDLINE (1946 to August 2017), Ovid Embase (1974 to August 2017), Ovid Evidence-Based Medicine Reviews (i.e., Ovid version of the Cochrane Library; inception to August 2017), Ovid International Pharmaceutical Abstracts (1970 to January 2014; update searches were not conducted in this database because of cancellation of the database subscription), and EBSCO Cumulative Index to Nursing and Allied Health Literature (inception to August 2017) was conducted in January 2014 and last updated in August 2017. Cited reference searching of the included studies was done using the Scopus database. The detailed search strategy and list of search terms is outlined in Appendix 1 (Supplementary Material). Two reviewers independently reviewed the titles, abstracts, and full-text articles to determine if they met the inclusion criteria. A third researcher was used to resolve any discrepancies. Data of included studies were independently abstracted by 2 reviewers and confirmed by a third researcher. Studies were included if they met the following criteria: (1) a pharmacist was involved in the care of patients, (2) studies had a quasi-experimental or experimental design, and (3) studies were conducted in an LTC population. Studies published in any language were included. For studies that included mixed populations (e.g., LTC in addition to community-dwelling or hospitalized patients), data were abstracted from only the LTC portion of the population. Studies were excluded if the role of the pharmacist was not clearly described, or if there was no control group for comparison. Pharmacist interventions were categorized into 4 different activities: case conference, medication review, documentation, and education. Categories were determined independently by 1 researcher, by review of the description of pharmacist interventions, and confirmed by another researcher.
Outcomes and analysis Data on 3 separate outcome categories were abstracted. These categories were medication related, health system, and clinical outcomes. Medication outcomes included measurements, such as overall reduction or changes in the regimen, as well as targeted reduction (e.g., in psychotropic medication). Medication measures of appropriateness (e.g., the Medication Appropriateness Index [MAI], Beers Criteria, potentially inappropriate prescriptions [PIPs] by Screening Tool of Older People’s Prescriptions [STOPP] criteria) were also identified. Clinical measures that were abstracted included outcomes such as falls and mortality. Health system outcomes were related to hospital admissions and cost. For hospitalizations and mortality data, meta-analysis using Review Manager 5.3 was used. Odds ratios (ORs), using a random effects model, were calculated with 95% CIs.
SCIENCE AND PRACTICE Pharmacists’ role and impact in long-term care
how this was reported (chronic or chronic and as-needed medications) differed from study to study.
Results From the 1318 articles originally screened, a total of 26 studies were included in the final analysis (Figure 1). Studies with multiple publications were considered together.
Medication outcomes Medication-related outcomes and how they were reported varied from study to study. Decrease in number of medications was the most commonly used outcome, and it was reported by 11 studies (42%).20,21,24,25,27,28,30,35,38,39,41,46,49 There was a statistically significant decrease, in the intervention group, in 7 of those studies (see Table 2).20,21,27,35,41,46,49 A number of studies (n ¼ 6) specifically reported on the decreased use of psychotropics, including hypnotics and benzodiazepines,22,25,26,31,34,39 with 4 (67% of those who reported) of those studies finding a statistically significant decrease in the intervention group.25,31,34,39 Improvement in MAI and PIPs was seen in 4 studies,20,21,23,42 whereas improvement in the Beers Criteria was seen in 1 study.42 Overall, 5 studies (19%) showed no statistically significant change or improvement in medication use with pharmacist intervention, either as a decrease in number of medications or
Study characteristics Table 1 describes the study characteristics and patient demographics of the included studies. The most common study design was a randomized controlled trial (n ¼ 14). Studies were primarily conducted in Europe (12 studies), the United States (7 studies), and Australia (5 studies). Studies ranged in size from 30 to 7362 patients (median study size ¼ 318). The most common activity was medication review with 24 studies (92%) including that activity, followed by documentation (n ¼ 15). Study length varied from 1 to 60 months, with the median duration being 12 months. With respect to patient characteristics, most participants in each study were female patients. In 17 studies, the average age was more than 80 years. The mean number of drugs at baseline ranged from 5 to 14; however,
Records idenfied through database searching (n = 1170)
Addional records idenfied through other sources (Cited reference searching n = 479)
Records aer 339 duplicates removed (n = 1310)
Records screened (n = 1310 )
Records excluded by tle and abstract search (n = 1259)
Full-text arcles assessed for eligibility (n =51)
Full-text arcles excluded, (n = 19) No control group (n=9) Not in LTC (n=3)
Studies included in systemac review (n = 32 papers, represenng 26 unique studies
Reviews/Posion statements (n=2) Complete results not available (n=5)
Figure 1. Flow diagram of study selection.
3
No.
Study characteristics World region
5
King et al.24 (2001)
6 7
Roberts et al.25 (2001) Westbury et al.26 (2009)
2
8 9
10
11 12 13 14 15
16
17 18
Europe Brulhart et al.27 (2011), Switzerland Burns et al.28 (2000), Furniss et al.29 (2000), United Kingdom Claesson et al.30 (1998), Schmidt31,32 (1998a, 1998b), Sweden Da Costa et al.33 (2016), Portugal Eide et al.34 (2001), Norway Jodar-Sanchez et al.35 (2014), Spain Kersten et al.36 (2013), Norway Midlov et al.37 (2002), Sweden
Patterson et al.38-40 (2010a, 2010b, 2011) United Kingdom Strikwerdet al.41 (1994), the Netherlands Verrue et al.42 (2012), Belgium
Subject characteristics Design
Population size
BSPharm intervention Case conference
Medication review
Documentation
Education
Sex (% F)
Mean age (y)
No. medications prescribed, mean
RCT (by patient)
359
X
X
d
d
I: 71%; C: 63%
NR
I: 8.8; C: 8.2
RCT (by patient)
306
X
X
d
d
I: 71%; C: 63%
NR
I: 8.7; C: 8.1
RCT (by site) RCT (by site)
715 154
d X
d X
d d
X X
245
X
X
d
d
I: 84.7; C: 83.4 I: 85.3; C1: 83.6; C2: 84.6 I: 78.9; C: 80.2
NR I: 6.0; C1: 6.0; C2: 5.9
Nonrandomized control RCT (by site) Nonrandomized control
I: 86; C: 82 I: 56; C1: 57; C2: 66 I: 81; C: 65
3230 1591
d d
X X
X X
X X
NR NR
NR NR
NR Patients on psychotropics (%): I: 61.1%; C: 62.4% Patients on BZD (%): I: 31.9%; C: 30.4%
Observational
329
X
X
X
d
I: 76
I: 83
9.8
RCT (by site)
330
d
X
X
d
I: 79; C: 67
I: 83.5; C: 78.9
I: 14.2; C: 13.3
RCT (by site)
1854
X
X
X
d
I: 70; C: 67
I: 83; C: 83
I: 7.5; C: 7.8
126
d
X
X
d
I: 71%; C: 67%
I: 85.2; C:84.5
I: 10; C: 9 (median)
280
d
d
d
X
I: 75; C: 85
I: 85.7; C: 87.2
NR
I: 8.3; C: 7.5
Nonrandomized control Nonrandomized control Nonrandomized control RCT (by patient)
332
X
d
d
I: 71; C: 57
I: 82.2; C: 80.5
I: 6.7; C: 4.9
101
X
d
d
I: 83; C: 75
I: 86; C: 85
I: 10; C: 9
RCT (by site)
157
X
X
X
d
RCT (by site)
334
X
X
X
d
Epilepsy group: I: 61; C: 58 Parkinson group: I: 49; C: 58 I: 72; C: 73
Epilepsy group: I: 78.6; C: 79.8 Parkinson group: I: 80.7; C: 82.2 I: 82.6; C: 82.9
Epilepsy group: I: 8.3; C: 8.2 Parkinson group: I: 8.8; C: 8.3 I: 7.6; C: NR
RCT (by physician)
196
d
X
X
d
I: 54; C1:71; C2: 60
NR
Overall: 6.5
Nonrandomized control
192
d
X
X
d
I: 75; C: 66
I: 86.0; C: 79.9
Chronic medications: I: 7; C: 6
C.A. Sadowski et al. / Journal of the American Pharmacists Association xxx (2019) 1e9
3 4
Asia Frankenthal et al.20 (2014), Israel Frankenthal et al.21 (2017), Israel Australia Crotty et al.22 (2004a) Crotty et al.23 (2004b)
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Table 1 Characteristics of included studies
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Mean number of prescriptions filled in 3 mo: I: 29; C: 28 I: 77.6; C: 78.7 I: 75; C: 78
I: 7.9; C: 7.2
I: 82.0; C: 83.7 65-74 y: I: 16.3%; C: 15.8% 75-84 y: I: 35.9%; C: 35.3% 85þ y: I: 39.7%; C: 36.4% I: 85.1; C: 86.3 I: 68; C: 77 I: 72; C: 68
I: 82; C: 85
NR NR
I: 14.2; C: 13.3 6-9: I: 32.9%; C: 33.3% 10: I: 53.9%; C: 53.7%
I: 85.7; C: 85.3 I: 80.3; C: 80.9 I: 84; C: 85 I: 71; C: 75
I: 7.6; C: 5.9
I: 85.3; C: 84.6
NR NR
in appropriateness criteria,24,28,37,44,50 although 2 were trending toward improvements.24,28
I: 87; C: 76
I: 6.9; C: 6.9
Pharmacists’ role and impact in long-term care
Costs Medication costs were reported in 14 studies (54%).20,21,23-25, Most of those reporting this outcome found a decrease in medication costs in the intervention group,20,21,25,28,35,39,45,50 although only 4 studies found a statistically significant cost reduction.20,21,28,50 Frankenthal et al.20 found that medication reviews using STOPP/START Screening Tool to Alert Doctors to the Right Treatment (START) criteria reduced average medication costs per patient per month, and these cost savings were maintained at 24 months following the initial medication review.21 Burns et al.28 found that pharmacistconducted medication reviews reduced total costs, which were calculated to include such things as physician visits, inpatient days, pharmacist hours, and medication. Trygstad et al.50 found similar cost savings to Frankenthal et al.,20 reporting that medication review reduced costs per member per month.
27,28,35,39,42,43,45,50,51
d 7362 26
Abbreviations used: RCT, randomized controlled trial; BZD, benzodiazepines; C, control group; I, intervention group; NR, not reported.
d X X
d d d 152
Non-randomized control Nonrandomized control Thompson et al.49 (1984) Trygstad et al.50,51 (2005, 2009) 25
X
d d d X d d 411 249 Horning et al.47 (2007) Lapane et al.48 (2011) 23 24
X X
X d d 52 Hood et al.46 (1975) 22
X
X d X X X X d d 516 30
RCT (by site) Nonrandomized control Nonrandomized control Chart review RCT (by site) 20 21
19
Zermansky et al.43 (2006), United Kingdom United States Clifton et al.44 (2000) Cooper et al.45 (2005)
d 661 RCT (by patient)
X
X
d
Hospitalizations and mortality Hospitalizations were reported in 10 studies (38%)20,21,25,29,43-45,48-50; however, only 5 studies had the exact number of hospitalizations for each group and therefore could be meta-analyzed.43-45,48,49 Figure 2 depicts the hospitalization data. With respect to hospitalizations, there was a high level of heterogeneity with this outcome (I2 ¼ 59%) making interpretation difficult. Clifton et al.44 found that residents in the intervention group had higher rates of hospitalization (P ¼ 0.042). In the almost 5000 patients included in this metaanalysis, there was no difference in hospitalizations between intervention and control (OR 0.77 [95% CI 0.55e1.08]). For mortality (Figure 2), there were 8 studies reporting on this outcome,25,29,35,43-45,48,49 and only 7 studies had exact number of deaths in each group and therefore could be metaanalyzed.29,35,43-45,48,49 Of these studies, only Furniss et al.28 found a statistically significant change, reporting 14 deaths in the control arm compared with 4 deaths in the intervention arm at 4 months after medication review (P ¼ 0.028). Heterogeneity in the random effects model was minimal (I2 ¼ 0), reflecting the similarity in findings between studies. The pooled result is leaning toward a positive effect in favor of pharmacist intervention, showing a 9% reduction in mortality; however, this was not statistically significant (OR 0.91 [95% CI 0.79e1.05]). Falls In terms of fall reduction, of the 5 studies (19%)22,29,38,43,48 that reported this outcome, only 1 found a statistically significant change, reporting a 0.5 fall per patient reduction in favor of the intervention.43 Risk of bias The quality of studies was assessed using the Cochrane Risk of Bias v2 tool, which demonstrated that almost all studies were high risk of bias. This was primarily because of the lack of blinding that is possible with pharmacist and team-based 5
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Table 2 Results for trials reporting on the mean number of medications per patient Study
Mean number of medications/patient (unless otherwise noted)
Statistical significance Significant reduction in intervention group
King et al.24 (2001) Roberts et al25 (2001) Brulhart et al.27 (2011) Furniss et al.28 (2000)
I: 8.8-7.3 (P 0.01); C: 8.2-8.9; P 0.001 (between groups) I: 8.7-7.2 (P 0.001); C: 8.1-8.2 (P ¼ 0.84); P ¼ 0.03 (between groups) I: 0.35; C: 0.03; P ¼ 0.37 (between groups) I: 6.60; C: 7.45; P ¼ 0.15 (between groups) I: 12.8-11.8 (P < 0.01) I: 5.1-4.2; C: 4.9-4.4; P ¼ 0.07 (between groups)
Claesson et al.30 (1998) Jodar-Sanchez et al.35 (2015)
I: 7.5-7.8; C: 7.8-8.2 I: 6.4-5.9 (P < 0.001); C: 4.8-5.9 (P < 0.001)
Strikwerda et al.41 (1994)
Number of deleted drugs: I: 7%; C: 3%; P < 0.05 (between groups) I: 7.6-6.7 (P < 0.01); C: 5.9-6.1 (NS) I: prestudy year 7.9-5.7; C: prestudy year 7.2-7.1; P ¼ 0.04 between control and treatment groups after study year
Frankenthal et al.20 (2014) Frankenthal et al.21 (2017)
46
Hood et al. (1975) Thompson et al.49 (1984)
interventions, particularly when the study took place in a single facility (Appendix 2). Discussion The purpose of this study was to systematically review the literature regarding the impact of pharmacist interventions in LTC. Our study focused on 3 types of outcomes, with those being medication outcomes, clinical measures, and health system outcomes. This review found tremendous diversity in studies investigating the impact of pharmacist intervention in LTC (e.g., design, duration, and
Significant reduction in intervention group No significant difference between groups No significant difference between groups Significant reduction in intervention group No significant difference between within group changes Significance not reported Significant reduction in intervention group; significant increase in control group Significant increase in the number of deleted medications in the intervention group Significant reduction in the intervention group Significantly fewer medications in the intervention group
primary outcome measures). Pharmacist interventions were often part of a larger team-based intervention (19 of the 26 studies) and included a mixture of a few standard approaches (e.g., medication review, documentation, case conferences, and education). More than half of the studies reporting on overall medication usage found that pharmacist intervention reduced medication usage or improved medication appropriateness. Studies reporting on clinical measures and health system outcomes found few statistically significant differences; however, 8 out of 14 studies reported that pharmacist interventions reduced medication/health care costs.
Figure 2. Forest plots comparing (A) hospitalizations in intervention versus control and (B) mortality in intervention versus control.
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With respect to cost outcomes, a systematic review by Hasan et al.52 found similar results to those reported in our study. In this study, researchers looked specifically at the cost outcomes of conducting pharmacist-led medication reviews for residents of LTC. Here, they found that 6 out of the 8 studies included in the review reported a cost benefit in favor of medication reviews.52 The studies included in our systematic review, as well as those by Hasan et al.,52 are quite heterogeneous with respect to how costs were reported and the health care systems in which they were conducted, making comparisons difficult. Our systematic review is also consistent with another review of pharmacist services in nursing homes, which reported that pharmacists improved some measures of medication appropriateness, and their interventions led to reduced falls.53 In contrast to our systematic review, this study by Lee et al., included studies with any study design, and many that did not have a control group. However, the impact that pharmacist intervention has on clinical measures and hospitalizations is less clear. There are a number of potential reasons for this, one being the short duration and small sample sizes of the included studies. Most studies were likely too short and underpowered to detect statistically significant changes in mortality, hospitalizations, and falls. The 1 study that did find increased mortality in the intervention group28 might have had this unexpected finding because of the pharmacist’s primary focus on heart failure management, rather than overall patient assessment. Another potential contributor to minimal impact on clinical outcomes was the lack of direct face-to-face interaction between the pharmacist and prescriber. The primary route of communication between the pharmacist and prescriber was often at times via indirect means (e.g., written letter), which could have contributed to some of the negative findings. The consultant role and intermittent presence of health professionals in the facilities leads to inconsistent team presence. These negative findings may spark further research regarding the types of communication that take place in this setting. For example, to maximize the impact of pharmacist services in LTC, pharmacists may have greater impact via a face-to-face conversation with the physician and nursing staff. Four of the included studies reported pharmacist recommendation acceptance rates of less than 50%, again speaking to the importance of direct communication. A systematic review by Lee et al., which looked at evaluating the effect of only medication reviews on mortality and hospitalizations in nursing home residents, was published in 2014. This review included any team structure or health professional conducting the reviews, and some studies did not even include a pharmacist. However, similar to our study, they reported that medication reviews had little effect on mortality or hospitalizations. Given the frailty and complexity of older adults, this is not surprising, as mortality is often very high in this population. In addition, there may be policies relating to hospital admissions, preventing frail older adults from unnecessary hospitalizations. Researchers found a high degree of study heterogeneity, with most studies being of overall lower quality, again echoing the findings of our study. When evaluating the lack of change seen in clinical measures, another factor that must be considered is the expanding scope of pharmacist practice that is taking place across the
world.54-56 In Canada, 2 randomized controlled trials conducted in community-dwelling patients have shown the effect that pharmacists can have when practicing at full scope (e.g., conducting risk assessments, educating patients, prescribing medications, ordering laboratory monitoring, and conducting regular follow-up visits).18,19 These studies found that pharmacists practicing at full scope can improve blood pressure and low-density lipoprotein cholesterol, 2 well-established surrogate markers.18,19 When one considers the evidence of pharmacist impact, in addition to the context of care delivery in LTC facilities, such as intermittent physician contact, or lessregulated health professionals, it is possible to see the potential benefit that a full-scope pharmacist practicing in LTC could bring. Strengths of our systematic review include its focus on LTC as a unique setting for geriatric care delivery and broad inclusion criteria (e.g., studies published in any language). To the best of our knowledge, our study is the first to investigate the impact of broader scope pharmacist interventions in LTC facilities and to conduct a meta-analysis on study outcomes. By focusing on the LTC population, we were able to help fill a gap in the medical literature, as most preexisting systematic reviews on pharmacist services have focused on services provided in the community.57 Furthermore, pharmacists’ scope of practice is expanding around the world (e.g., administering injections, prescribing).9-15 By including all types of pharmacist interventions, we were able to comprehensively evaluate the impact of pharmacist services in LTC. This is in contrast to other reviews that have focused on only medication reviews.52,53 With respect to the limitations of this review, including multiple types of pharmacist interventions and study designs made drawing focused conclusions difficult. Results must be interpreted with caution, given the lack of high-quality studies in this area.
Conclusion There is evidence to support pharmacist intervention, primarily through medication review, to reduce drug usage and improve measures in the appropriateness of medications. Overall, current evidence suggests that pharmacist interventions in LTC lead to some cost savings, through reductions in medication costs. However, further randomized controlled studies of adequate duration involving full-scope pharmacist interventions are required. In addition, these studies should include outcomes such as medication appropriateness and hospitalizations. This will help us to determine the optimal role for pharmacists in providing care in the LTC setting. Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.japh.2019.11.014 References 1. Centers for Medicare and Medicaid Services. Nursing home data compendium 2015 edition. Available at: https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/CertificationandComplianc/Downloads/ nursinghomedatacompendium_508-2015.pdf. Accessed October 11, 2019.
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2. Health at a Glance 2017. Recipients of long-term care. Available at: https://www.oecd-ilibrary.org/social-issues-migration-health/health-ata-glance-2017/recipients-of-long-term-care_health_glance-2017-77-en. Accessed March 25, 2018. 3. Schram MT, Frijters D, van de Lisdonk EH, et al. Setting and registry characteristics affect the prevalence and nature of multimorbidity in the elderly. J Clin Epidemiol. 2008;61(11):1104e1112. 4. Jokanovic N, Tan EC, Dooley MJ, Kirkpatrick CM, Bell JS. Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review. J Am Med Dir Assoc. 2015;16(6): 535.e1e535.e12. 5. De Silva TR, Theou O, Vellas B, Cesari M, Visvanathan R. Frailty Screening (FRAIL-NH) and mortality in French nursing homes: results from the incidence of pneumonia and related consequences in nursing home residents study. J Am Med Dir Assoc. 2018;19(5):411e414. 6. Rockwood K, Stolee P, McDowell I. Factors associated with institutionalization of older people in Canada: testing a multifactorial definition of frailty. J Am Geriatr Soc. 1996;44(5):578e582. 7. Tam SHY, Hirsch JD, Watanabe JH. Medication regimen complexity in long-term care facilities and adverse drug events-related hospitalizations. Consult Pharm. 2017;32(5):281e284. 8. Latter S, Blenkinsopp A. Non-medical prescribing: current and future contribution of pharmacists and nurses. Int J Pharm Pract. 2011;19(6): 381e382. 9. Pharmaceutical Society of New Zealand Incorporated. New Zealand National Pharmacist Services Framework 2014. Available at: https://www.psnz.org. nz/Folder?Action¼View%20File&Folder_id¼86&File¼PSNZPharmacist ServicesFramework2014FINAL.pdf. Accessed October 21, 2019. 10. American College of Clinical Pharmacy, McBane SE, Dopp AL, et al. Collaborative drug therapy management by and comprehensive medication management-2015. Pharmacotherapy. 2015;35(4):e39ee50. 11. Canadian Pharmacists Association. Pharmacists’ scope of practice in Canada. Available at: https://www.pharmacists.ca/cpha-ca/assets/File/ cpha-on-the-issues/ScopeofPracticeinCanada_DEC2016.pdf. Accessed March 25, 2018. 12. The Pharmaceutical Society of Ireland. Seasonal influenza vaccination programme in pharmacies evidence base and framework. Available at: http://www.lenus.ie/hse/handle/10147/234069. Accessed October 21, 2019. 13. Francis M, Hinchliffe A. Vaccination services through community pharmacy: a literature review. Available at: http://www2.nphs.wales.nhs. uk:8080/HealthServiceQDTDocs.nsf/public/CBDDC3C0BE94493980257 93B00341A6F/$file/Vaccination%20services%20through%20community %20pharmacy%20v1a.pdf. Accessed February 26, 2013. 14. 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. Arch Intern Med. 2011;171(16):1441e1453. 15. Tan EC, Stewart K, Elliott RA, George J. Pharmacist services provided in general practice clinics: a systematic review and meta-analysis. Res Social Adm Pharm. 2014;10(4):608e622. 16. Hughes CA, Breault RR, Hicks D, Schindel TJ. Positioning pharmacists’ roles in primary health care: a discourse analysis of the compensation plan in Alberta, Canada. BMC Health Serv Res. 2017;17(1):770. 17. Houle SK, Grindrod KA, Chatterley T, Tsuyuki RT. Paying pharmacists for patient care: a systematic review of remunerated pharmacy clinical care services. Can Pharm J (Ott). 2014;147(4):209e232. 18. Tsuyuki RT, Houle SK, Charrois TL, 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(2):93e100. 19. Tsuyuki RT, Rosenthal M, Pearson GJ. A randomized trial of a communitybased approach to dyslipidemia management: pharmacist prescribing to achieve cholesterol targets (RxACT study). Can Pharm J (Ott). 2016;149(5):283e292. 20. Frankenthal D, Lerman Y, Kalendaryev E, Lerman Y. Intervention with the screening tool of older persons potentially inappropriate prescriptions/ screening tool to alert doctors to right treatment criteria in elderly residents of a chronic geriatric facility: a randomized clinical trial. J Am Geriatr Soc. 2014;62(9):1658e1665. 21. Frankenthal D, Israeli A, Caraco Y, et al. Long-term outcomes of medication intervention using the screening tool of older persons potentially inappropriate prescriptions screening tool to alert doctors to right treatment criteria. J Am Geriatr Soc. 2017;65(2):e33ee38. 22. Crotty M, Whitehead C, Rowett D, et al. An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial [ISRCTN67855475]. BMC Health Serv Res. 2004;4(6):1e6. 23. Crotty M, Halbert J, Rowett D, et al. An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing. Age Ageing. 2004;33(6):612e617.
8
24. King MA, Roberts MS. Multidisciplinary case conference reviews: improving outcomes for nursing home residents, carers and health professionals. Pharm World Sci. 2001;23(2):41e45. 25. Roberts MS, Stokes JA, King MA, et al. Outcomes of a randomized controlled trial of a clinical pharmacy intervention in 52 nursing homes. Br J Clin Pharmacol. 2001;51(3):257e265. 26. Westbury J, Jackson S, Gee P, Peterson G. An effective approach to decrease antipsychotic and benzodiazepine use in nursing homes: the RedUSe project. Int Psychogeriatr. 2010;22(1):26e36. 27. Brulhart MI, Wermeille JP. Multidisciplinary medication review: evaluation of a pharmaceutical care model for nursing homes. Int J Clin Pharm. 2011;33(3):549e557. 28. Furniss L, Burns A, Craig SK, Scobie S, Cooke J, Faragher B. Effects of a pharmacist’s medication review in nursing homes. Randomised controlled trial. Br J Psychiatry. 2000;176(6):563e567. 29. Burns A, Furniss L, Cooke J, Lloyd Craig SK, Scobie S. Pharmacist medication review in nursing homes: a cost analysis. Int J Geriatr Psychopharmacol. 2000;2(3):137e141. 30. Claesson CB, Schmidt IK. Drug use in Swedish nursing homes. Clin Drug Investig. 1998;16(6):441e452. 31. Schmidt I, Claesson CB, Westerholm B, Nilsson LG, Svarstad BL. The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. J Am Geriatr Soc. 1998;46(1): 77e82. 32. Schmidt IK, Claesson CB, Westerholm B, Nilsson LG. Physician and staff assessments of drug interventions and outcomes in Swedish nursing homes. Ann Pharmacother. 1998;32(1):27e32. 33. da Costa FA, Silvestre L, Periquito C, et al. Drug-related problems identified in a sample of Portuguese institutionalised elderly patients and pharmacists’ interventions to improve safety and effectiveness of medicines. Drugs Real World Outcomes. 2016;3(1):89e97. 34. Eide E, Schjøtt J. Assessing the effects of an intervention by a pharmacist on prescribing and administration of hypnotics in nursing homes. Pharm World Sci. 2001;23(6):227e231. dar-S pez del Amo MP, García L, Araújo-Santos JM, 35. Jo anchez F, Martín JJ, Lo Epstein D. Cost-utility analysis of a pharmacotherapy follow-up for elderly nursing home residents in Spain. J Am Geriatr Soc. 2014;62(7): 1272e1280. 36. Kersten H, Molden E, Tolo IK, Skovlund E, Engedal K, Wyller TB. Cognitive effects of reducing anticholinergic drug burden in a frail elderly population: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2013;68(3):271e278. € v P, Bondesson A, Eriksson T, Petersson J, Minthon L, Ho € glund P. 37. Midlo Descriptive study and pharmacotherapeutic intervention in patients with epilepsy or Parkinson’s disease at nursing homes in southern Sweden. Eur J Clin Pharmacol. 2002;57(12):903e910. 38. Patterson SM, Hughes CM, Crealey G, Cardwell C, Lapane KL. An evaluation of an adapted U.S. model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood Northern Ireland Study). J Am Geriatr Soc. 2010;58(1):44e53. 39. Patterson SM, Hughes CM, Cardwell C, Lapane KL, Murray AM, Crealey GE. A cluster randomized controlled trial of an adapted U.S. model of pharmaceutical care for nursing home residents in Northern Ireland (Fleetwood Northern Ireland Study): a cost-effectiveness analysis. J Am Geriatr Soc. 2011;59(4):586e593. 40. Patterson SM, Crealey G, Lapane KL, Hughes CM. Description of interventions performed during the Fleetwood Northern Ireland Study. J Appl Ther Res. 2010;7(3):101e109. 41. Strikwerda P, Bootsma-de Langen AM, Berghuis F, Meyboom-de Jong B. [Drug therapy in a nursing home; favorable effect of feedback by the pharmacist on family physician's prescribing behavior]. Ned Tijdschr Geneeskd. 1994;138(35):1770e1774. 42. Verrue C, Mehuys E, Boussery K, Adriaens E, Remon JP, Petrovic M. A pharmacist-conducted medication review in nursing home residents: impact on the appropriateness of prescribing. Acta Clin Belg. 2012;67(6): 423e429. 43. Zermansky AG, Alldred DP, Petty DR, et al. Clinical medication review by a pharmacist of elderly people living in care homes–randomised controlled trial. Age Ageing. 2006;35(6):586e591. 44. Clifton GD, Ranz TT, Blumenschein K, Lehman ME. Heart failure guideline use in long term care facilities: consultant pharmacist initiated approach to improve awareness. Consult Pharm. 2000;15(6):623e630. 45. Cooper JW, Wade WE. Pharmacist interventions in geriatric nursing facility NSAID therapy: a one-year follow-up study of costs and outcomes. Consult Pharm. 2005;20(6):492e497. 46. Hood JC, Lemberger M, Stewart RB. Promoting appropriate therapy in a long-term care facility. J Am Health Care Assoc. 1975;1(2):10e13. 47. Horning KK, Hoehns JD, Doucette WR. Adherence to clinical practice guidelines for 7 chronic conditions in long-term-care patients who
SCIENCE AND PRACTICE Pharmacists’ role and impact in long-term care
48.
49.
50.
51.
52.
53.
received pharmacist disease management services versus traditional drug regimen review. J Manag Care Pharm. 2007;13(1):28e36. Lapane KL, Hughes CM, Daiello LA, Cameron KA, Feinberg J. Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes. J Am Geriatr Soc. 2011;59(7):1238e1245. Thompson JF, McGhan WF, Ruffalo RL, Cohen DA, Adamcik B, Segal JL. Clinical pharmacists prescribing drug therapy in a geriatric setting: outcome of a trial. J Am Geriatr Soc. 1984;32(2):154e159. Trygstad TK, Christensen DB, Wegner SE, Sullivan R, Garmise JM. Analysis of the North Carolina long-term care polypharmacy initiative: a multiplecohort approach using propensity-score matching for both evaluation and targeting. Clin Ther. 2009;31(9):2018e2037. Trygstad TK, Christensen D, Garmise J, Sullivan R, Wegner S. Pharmacist response to alerts generated from Medicaid pharmacy claims in a longterm care setting: results from the North Carolina polypharmacy initiative. J Manage Care Pharm. 2005;11(7):575e583. Hasan SS, Thiruchelvam K, Kow CS, Ghori MU, Babar ZU. Economic evaluation of pharmacist-led medication reviews in residential aged care facilities. Expert Rev Pharmacoecon Outcomes Res. 2017;17(5):431e439. Lee SWH, Mak VSL, Tang YW. Pharmacist services in nursing homes: a systematic review and meta-analysis. Br J Clin Pharmacol. 2019. https:// doi.org/10.1111/bcp.14101.
54. Ramalho de Oliveira D, Brummel AR, Miller DB. Medication therapy management: 10 years of experience in a large integrated health care system. J Manag Care Pharm. 2010;16(3):185e195. 55. Manolakis PG, Skelton JB. Pharmacists’ contributions to primary care in the United States collaborating to address unmet patient care needs: the emerging role for pharmacists to address the shortage of primary care providers. Am J Pharm Educ. 2010;74(10):S7. 56. Agomo CO. The role of community pharmacists in public health: a scoping review of the literature. J Pharm Health Serv Res. 2012;3(1):25e33. 57. Jokanovic N, Tan EC, Sudhakaran S, et al. Pharmacist-led medication review in community settings: an overview of systematic reviews. Res Social Adm Pharm. 2017;13(4):661e685. Cheryl A. Sadowski, BSc(Pharm), PharmD, BCGP, FCSHP, Professor, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, AB Theresa L. Charrois, BScPharm, ACPR, MSc, Clinical Associate Professor, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB Evan Sehn, BScPharm, PharmD, Clinical Pharmacist, Sobeys Inc, Lethbridge, AB Trish Chatterley, BA, MLIS, Collection Strategies Coordinator, University of Alberta, Edmonton, AB Sujin Kim, BScPharm, Clinical Pharmacist, Rite Aid Pharmacy, Federal Way, WA
9
SCIENCE AND PRACTICE C.A. Sadowski et al. / Journal of the American Pharmacists Association xxx (2019) 1e9
Appendix 1. Search strategy
1. 2. 3. 4.
drug information services/ or medication therapy management/ "drug utilization review"/ Pharmaceutical Services/ ((drug or medication or medicine* or prescription*) adj2 (manag* or therapy or review* or audit* or consult* or monitor* or screen* or counsel* or recommend*)).ti,ab. 5. (prescription adaptation or therapeutic substitution or prescription renewal*).mp. 6. pharmaceutical case management.mp. 7. (pharmaceutical care or disease state management).mp. 8. (pharmacist$ adj2 (prescribe or prescribes or prescribing)).mp. 9. ((independent or supplementary or nonmedical or non-medical or repeat or collaborative) adj prescrib$).mp. 10. (pharmaceutical opinion* or "refusal to dispense" or "refusal to fill").mp. 11. (pharmacist* adj4 intervention*).mp. 12. (cognitive adj2 service*).mp. 13. clinical pharmac*.mp. 14. "Referral and consultation"/ 15. Directive Counseling/ or counseling/ 16. "utilization review"/ or "concurrent review"/ 17. Patient education as topic/ 18. patient care management/ or case management/ 19. follow-up.mp. 20. (clinical adj2 (care or service*)).mp. 21. (educat* or counsel* or consult*).mp. 22. academic detailing.mp. 23. or/1-22 24. Pharmacists/ or exp pharmaceutical services/ 25. pharmacist*.mp. 26. 24 or 25 27. 23 and 26 28. Homes for the aged/ 29. residential facilities/ or assisted living facilities/ or group homes/ or exp nursing homes/ 30. (nursing adj2 (home*1 or unit*1 or center*1 or centre*1)).ti,ab. 31. (group adj2 home*).ti,ab. 32. (long-term care adj2 facilit*).ti,ab. 33. (care adj2 (home* or facilit*)).ti,ab. 34. (rest adj2 home*).ti,ab. 35. (residential adj2 (home* or care)).ti,ab. 36. (geriatric adj2 (home* or unit* or facilit* or institution*)).ti,ab. 37. Long-Term care/ 38. ((long-term or longterm or continuing) adj2 care).ti,ab. 39. ((supportive or assisted or institutional) adj2 living).ti,ab. 40. Institutionalization/ 41. or/29-40 42. exp aged/ 43. (aged or old people or older people or old persons or older persons or old resident* or older resident* or elders or elderly or geriatric or senior*).ti,ab. 44. 42 or 43 45. 41 and 44 46. 28 or 45 47. clinical trial/ or controlled clinical trial/ or multicenter study/ or randomized controlled trial/ or comparative study/ or meta-analysis/ 48. Intervention studies/ 49. Double-Blind method/ 50. random*.ti,ab. 51. trial.ti,ab. or trials.ti. 52. (systematic* adj2 (review* or search*)).mp. 53. meta-analy*.mp. 54. review.pt. 55. or/47-54 56. 27 and 46 and 55
9.e1
SCIENCE AND PRACTICE Pharmacists’ role and impact in long-term care
Appendix 2. Risk of bias
No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
World region Asia Frankenthal et al.20 (2014), Israel Frankenthal et al.21 (2017), Israel Australia Crotty et al.22 (2004a) Crotty et al.23 (2004b) King et al.24 (2001) Roberts et al.25 (2001) Westbury et al.26 (2009) Europe Brulhart et al.27 (2011), Switzerland Burns et al.28 (2000), Furniss et al.29 (2000), United Kingdom Claesson et al.30 (1998), Schmidt et al.31,32 (1998a, 1998b), Sweden Da Costa et al.33 (2016), Portugal Eide et al.34 (2001), Norway Jodar-Sanchez et al.35 (2014), Spain Kersten et al.36 (2013), Norway Midlov et al.37 (2002), Sweden Patterson et al.38-40 (2010a, 2010b, 2011), United Kingdom Strikwerda et al.41 (1994), the Netherlands Verrue et al.42 (2012), Belgium Zermansky et al.43 (2006), United Kingdom United States Clifton et al.44 (2000) Cooper et al.45 (2005) Hood et al.46 (1975) Horning et al.47 (2007) Lapane et al.48 (2011) Thompson et al.49 (1984) Trygstad et al.50,51 (2005, 2009)
Risk of bias Some concerns Some concerns High High High High High
risk risk risk risk risk
of of of of of
bias bias bias bias bias
Some concerns High risk of bias High risk of bias High risk of bias High risk of bias High risk of bias Some concerns Some concerns High risk of bias High risk of bias High risk of bias Some concerns High High High High High High High
risk risk risk risk risk risk risk
of of of of of of of
bias bias bias bias bias bias bias
9.e2
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
REVIEW
The role and impact of the pharmacist in long-term care settings: A systematic review Cheryl A. Sadowski*, Theresa L. Charrois, Evan Sehn, Trish Chatterley, Sujin Kim a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 July 2019 Accepted 12 November 2019
Objective: Older adults in long-term care (LTC) are often frail and comorbid and have multiple medications. Although medication review by pharmacists has been integrated into LTC practice in many countries through policy and reimbursement models, the impact is variable in the literature. The purpose of our study was to review the literature regarding the impact of the pharmacist in LTC. Data sources: Four databases were searched from inception to September 2017, including Ovid MEDLINE, Ovid Embase, Ovid Evidence-Based Medicine Reviews (Cochrane Library), and Ovid International Pharmaceutical Abstracts. Study selection: Studies in any language were included if they met the following criteria: (1) pharmacist involved in care, (2) quasi-experimental or experimental design, and (3) conducted in LTC. Data extraction: Two reviewers independently reviewed the titles, abstracts, and full-text articles to determine if they met inclusion criteria, with a third researcher resolving discrepancies. Data of included studies were independently abstracted by 2 reviewers and confirmed by a third researcher. Results: Twenty-six studies (total N ¼ 20,228, median study duration ¼ 12 months) met the inclusion criteria. Medication review was the most common intervention, evaluated in 24 studies (92%). Eleven studies (42%) reported on the total number of medications per patient, with 7 studies finding a statistically significant reduction in medication usage. Six studies focused on psychotropic medications, with 4 of those leading to a reduction in medication. Explicit medication appropriateness criteria showed improvement in 5 studies. Medication and health care costs were evaluated in 14 studies (54%), with 4 reporting a statistically significant reduction. Studies reporting hospitalizations (10, 38%) were moderately heterogeneous (I2 ¼ 59%) and failed to demonstrate an impact. Studies reporting mortality (8, 31%) were less heterogeneous (I2 ¼ 0%), but they also failed to show a change. Conclusion: There is evidence to support pharmacist intervention, primarily through medication review, to improve measures in medication appropriateness. © 2019 Published by Elsevier Inc. on behalf of the American Pharmacists Association.
Introduction In 2015, 2.6% of seniors older than 65 years in the United States resided in nursing homes, although this dramatically increased to 9.5% of those aged 85 years and older.1 This
compares to 4.5% of seniors worldwide living in long-term care (LTC) facilities.2 This group of seniors is usually characterized by frailty, multimorbidity, and polypharmacy.3-6 With increased polypharmacy comes increased medication regimen complexity (MRC).7 There is an association
Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Funding: This work was supported by the Faculty of Pharmacy & Pharmaceutical Sciences Katz Endowment Fund, University of Alberta. The funder played no role in the design, execution, analysis, interpretation, or writing of this work. * Correspondence: Cheryl A. Sadowski, BSc(Pharm), PharmD, BCGP, FCSHP, Professor, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, AB T6G 1C9, Canada. E-mail address: [email protected] (C.A. Sadowski). https://doi.org/10.1016/j.japh.2019.11.014 1544-3191/© 2019 Published by Elsevier Inc. on behalf of the American Pharmacists Association.
SCIENCE AND PRACTICE C.A. Sadowski et al. / Journal of the American Pharmacists Association xxx (2019) 1e9
Methods Key Points Search strategy and selection criteria Background: Almost 5% of older adults worldwide are in longterm care facilities, and most of these individuals are frail and have polypharmacy. There is evidence that pharmacists improve disease focused outcomes in the outpatient and hospital settings, but the evidence supporting the effect of pharmacists in a multimorbid frail population in long-term care is uncertain. Findings: There are a number of studies conducted internationally on the pharmacist role in long-term care, but most studies are not randomized and have high risk of bias. Pharmacists in long-term care improve medication outcomes by increasing appropriateness, reducing the number of medications, and in particular, reducing psychotropics. Interventions by pharmacists in long-term care lead to reduced medication costs, but not reduced hospitalizations or mortality.
between increased MRC and an increase in adverse drug events (ADEs) and emergency department (ED) visits.7 Pharmacists’ skill sets and scope of practice put them in a position to help reduce MRC, prevent ADE and ED visits, and reduce health care expenditures. In several countries, the roles and responsibilities of pharmacists have expanded. Various forms of independent or collaborative pharmacist prescribing have been implemented in the United States, United Kingdom, New Zealand, and Canada.8-11 In the United States, United Kingdom, Ireland, Portugal, and Canada, pharmacists are authorized to administer injections.10-14 Pharmacists are also becoming increasingly more involved in the provision of primary care and chronic disease management.15,16 Remuneration models to help pay for these clinical pharmacy services have been implemented in several countries including the United States, United Kingdom, Australia, New Zealand, and Canada.17 Recent Canadian studies have clearly demonstrated the positive impact expanded pharmacy practice has on the control of patients with hypertension or dyslipidemia.18,19 It is hypothesized that seniors living in LTC could also reap the benefits that expanded pharmacy services can provide. However, despite the push for pharmacists to take on more clinical roles, few studies have analyzed the impact of pharmacist interventions on seniors living in LTC. Therefore, the objective of this review is to evaluate the effect of pharmacist-based interventions on medication, health system, and clinical outcomes in seniors living in LTC. Specifically, we attempted to determine if LTC settings that involve a pharmacist, compared with no pharmacist involvement, have improved medication, clinical, or health system outcomes using randomized or quasi-experimental studies.
2
For this systematic review, the Preferred Reporting Items for Systematic Reviews and Meta-analyses recommendations were followed. With the assistance of a medical librarian (TC), a comprehensive literature search of Ovid MEDLINE (1946 to August 2017), Ovid Embase (1974 to August 2017), Ovid Evidence-Based Medicine Reviews (i.e., Ovid version of the Cochrane Library; inception to August 2017), Ovid International Pharmaceutical Abstracts (1970 to January 2014; update searches were not conducted in this database because of cancellation of the database subscription), and EBSCO Cumulative Index to Nursing and Allied Health Literature (inception to August 2017) was conducted in January 2014 and last updated in August 2017. Cited reference searching of the included studies was done using the Scopus database. The detailed search strategy and list of search terms is outlined in Appendix 1 (Supplementary Material). Two reviewers independently reviewed the titles, abstracts, and full-text articles to determine if they met the inclusion criteria. A third researcher was used to resolve any discrepancies. Data of included studies were independently abstracted by 2 reviewers and confirmed by a third researcher. Studies were included if they met the following criteria: (1) a pharmacist was involved in the care of patients, (2) studies had a quasi-experimental or experimental design, and (3) studies were conducted in an LTC population. Studies published in any language were included. For studies that included mixed populations (e.g., LTC in addition to community-dwelling or hospitalized patients), data were abstracted from only the LTC portion of the population. Studies were excluded if the role of the pharmacist was not clearly described, or if there was no control group for comparison. Pharmacist interventions were categorized into 4 different activities: case conference, medication review, documentation, and education. Categories were determined independently by 1 researcher, by review of the description of pharmacist interventions, and confirmed by another researcher.
Outcomes and analysis Data on 3 separate outcome categories were abstracted. These categories were medication related, health system, and clinical outcomes. Medication outcomes included measurements, such as overall reduction or changes in the regimen, as well as targeted reduction (e.g., in psychotropic medication). Medication measures of appropriateness (e.g., the Medication Appropriateness Index [MAI], Beers Criteria, potentially inappropriate prescriptions [PIPs] by Screening Tool of Older People’s Prescriptions [STOPP] criteria) were also identified. Clinical measures that were abstracted included outcomes such as falls and mortality. Health system outcomes were related to hospital admissions and cost. For hospitalizations and mortality data, meta-analysis using Review Manager 5.3 was used. Odds ratios (ORs), using a random effects model, were calculated with 95% CIs.
SCIENCE AND PRACTICE Pharmacists’ role and impact in long-term care
how this was reported (chronic or chronic and as-needed medications) differed from study to study.
Results From the 1318 articles originally screened, a total of 26 studies were included in the final analysis (Figure 1). Studies with multiple publications were considered together.
Medication outcomes Medication-related outcomes and how they were reported varied from study to study. Decrease in number of medications was the most commonly used outcome, and it was reported by 11 studies (42%).20,21,24,25,27,28,30,35,38,39,41,46,49 There was a statistically significant decrease, in the intervention group, in 7 of those studies (see Table 2).20,21,27,35,41,46,49 A number of studies (n ¼ 6) specifically reported on the decreased use of psychotropics, including hypnotics and benzodiazepines,22,25,26,31,34,39 with 4 (67% of those who reported) of those studies finding a statistically significant decrease in the intervention group.25,31,34,39 Improvement in MAI and PIPs was seen in 4 studies,20,21,23,42 whereas improvement in the Beers Criteria was seen in 1 study.42 Overall, 5 studies (19%) showed no statistically significant change or improvement in medication use with pharmacist intervention, either as a decrease in number of medications or
Study characteristics Table 1 describes the study characteristics and patient demographics of the included studies. The most common study design was a randomized controlled trial (n ¼ 14). Studies were primarily conducted in Europe (12 studies), the United States (7 studies), and Australia (5 studies). Studies ranged in size from 30 to 7362 patients (median study size ¼ 318). The most common activity was medication review with 24 studies (92%) including that activity, followed by documentation (n ¼ 15). Study length varied from 1 to 60 months, with the median duration being 12 months. With respect to patient characteristics, most participants in each study were female patients. In 17 studies, the average age was more than 80 years. The mean number of drugs at baseline ranged from 5 to 14; however,
Records idenfied through database searching (n = 1170)
Addional records idenfied through other sources (Cited reference searching n = 479)
Records aer 339 duplicates removed (n = 1310)
Records screened (n = 1310 )
Records excluded by tle and abstract search (n = 1259)
Full-text arcles assessed for eligibility (n =51)
Full-text arcles excluded, (n = 19) No control group (n=9) Not in LTC (n=3)
Studies included in systemac review (n = 32 papers, represenng 26 unique studies
Reviews/Posion statements (n=2) Complete results not available (n=5)
Figure 1. Flow diagram of study selection.
3
No.
Study characteristics World region
5
King et al.24 (2001)
6 7
Roberts et al.25 (2001) Westbury et al.26 (2009)
2
8 9
10
11 12 13 14 15
16
17 18
Europe Brulhart et al.27 (2011), Switzerland Burns et al.28 (2000), Furniss et al.29 (2000), United Kingdom Claesson et al.30 (1998), Schmidt31,32 (1998a, 1998b), Sweden Da Costa et al.33 (2016), Portugal Eide et al.34 (2001), Norway Jodar-Sanchez et al.35 (2014), Spain Kersten et al.36 (2013), Norway Midlov et al.37 (2002), Sweden
Patterson et al.38-40 (2010a, 2010b, 2011) United Kingdom Strikwerdet al.41 (1994), the Netherlands Verrue et al.42 (2012), Belgium
Subject characteristics Design
Population size
BSPharm intervention Case conference
Medication review
Documentation
Education
Sex (% F)
Mean age (y)
No. medications prescribed, mean
RCT (by patient)
359
X
X
d
d
I: 71%; C: 63%
NR
I: 8.8; C: 8.2
RCT (by patient)
306
X
X
d
d
I: 71%; C: 63%
NR
I: 8.7; C: 8.1
RCT (by site) RCT (by site)
715 154
d X
d X
d d
X X
245
X
X
d
d
I: 84.7; C: 83.4 I: 85.3; C1: 83.6; C2: 84.6 I: 78.9; C: 80.2
NR I: 6.0; C1: 6.0; C2: 5.9
Nonrandomized control RCT (by site) Nonrandomized control
I: 86; C: 82 I: 56; C1: 57; C2: 66 I: 81; C: 65
3230 1591
d d
X X
X X
X X
NR NR
NR NR
NR Patients on psychotropics (%): I: 61.1%; C: 62.4% Patients on BZD (%): I: 31.9%; C: 30.4%
Observational
329
X
X
X
d
I: 76
I: 83
9.8
RCT (by site)
330
d
X
X
d
I: 79; C: 67
I: 83.5; C: 78.9
I: 14.2; C: 13.3
RCT (by site)
1854
X
X
X
d
I: 70; C: 67
I: 83; C: 83
I: 7.5; C: 7.8
126
d
X
X
d
I: 71%; C: 67%
I: 85.2; C:84.5
I: 10; C: 9 (median)
280
d
d
d
X
I: 75; C: 85
I: 85.7; C: 87.2
NR
I: 8.3; C: 7.5
Nonrandomized control Nonrandomized control Nonrandomized control RCT (by patient)
332
X
d
d
I: 71; C: 57
I: 82.2; C: 80.5
I: 6.7; C: 4.9
101
X
d
d
I: 83; C: 75
I: 86; C: 85
I: 10; C: 9
RCT (by site)
157
X
X
X
d
RCT (by site)
334
X
X
X
d
Epilepsy group: I: 61; C: 58 Parkinson group: I: 49; C: 58 I: 72; C: 73
Epilepsy group: I: 78.6; C: 79.8 Parkinson group: I: 80.7; C: 82.2 I: 82.6; C: 82.9
Epilepsy group: I: 8.3; C: 8.2 Parkinson group: I: 8.8; C: 8.3 I: 7.6; C: NR
RCT (by physician)
196
d
X
X
d
I: 54; C1:71; C2: 60
NR
Overall: 6.5
Nonrandomized control
192
d
X
X
d
I: 75; C: 66
I: 86.0; C: 79.9
Chronic medications: I: 7; C: 6
C.A. Sadowski et al. / Journal of the American Pharmacists Association xxx (2019) 1e9
3 4
Asia Frankenthal et al.20 (2014), Israel Frankenthal et al.21 (2017), Israel Australia Crotty et al.22 (2004a) Crotty et al.23 (2004b)
1
SCIENCE AND PRACTICE
4
Table 1 Characteristics of included studies
SCIENCE AND PRACTICE
Mean number of prescriptions filled in 3 mo: I: 29; C: 28 I: 77.6; C: 78.7 I: 75; C: 78
I: 7.9; C: 7.2
I: 82.0; C: 83.7 65-74 y: I: 16.3%; C: 15.8% 75-84 y: I: 35.9%; C: 35.3% 85þ y: I: 39.7%; C: 36.4% I: 85.1; C: 86.3 I: 68; C: 77 I: 72; C: 68
I: 82; C: 85
NR NR
I: 14.2; C: 13.3 6-9: I: 32.9%; C: 33.3% 10: I: 53.9%; C: 53.7%
I: 85.7; C: 85.3 I: 80.3; C: 80.9 I: 84; C: 85 I: 71; C: 75
I: 7.6; C: 5.9
I: 85.3; C: 84.6
NR NR
in appropriateness criteria,24,28,37,44,50 although 2 were trending toward improvements.24,28
I: 87; C: 76
I: 6.9; C: 6.9
Pharmacists’ role and impact in long-term care
Costs Medication costs were reported in 14 studies (54%).20,21,23-25, Most of those reporting this outcome found a decrease in medication costs in the intervention group,20,21,25,28,35,39,45,50 although only 4 studies found a statistically significant cost reduction.20,21,28,50 Frankenthal et al.20 found that medication reviews using STOPP/START Screening Tool to Alert Doctors to the Right Treatment (START) criteria reduced average medication costs per patient per month, and these cost savings were maintained at 24 months following the initial medication review.21 Burns et al.28 found that pharmacistconducted medication reviews reduced total costs, which were calculated to include such things as physician visits, inpatient days, pharmacist hours, and medication. Trygstad et al.50 found similar cost savings to Frankenthal et al.,20 reporting that medication review reduced costs per member per month.
27,28,35,39,42,43,45,50,51
d 7362 26
Abbreviations used: RCT, randomized controlled trial; BZD, benzodiazepines; C, control group; I, intervention group; NR, not reported.
d X X
d d d 152
Non-randomized control Nonrandomized control Thompson et al.49 (1984) Trygstad et al.50,51 (2005, 2009) 25
X
d d d X d d 411 249 Horning et al.47 (2007) Lapane et al.48 (2011) 23 24
X X
X d d 52 Hood et al.46 (1975) 22
X
X d X X X X d d 516 30
RCT (by site) Nonrandomized control Nonrandomized control Chart review RCT (by site) 20 21
19
Zermansky et al.43 (2006), United Kingdom United States Clifton et al.44 (2000) Cooper et al.45 (2005)
d 661 RCT (by patient)
X
X
d
Hospitalizations and mortality Hospitalizations were reported in 10 studies (38%)20,21,25,29,43-45,48-50; however, only 5 studies had the exact number of hospitalizations for each group and therefore could be meta-analyzed.43-45,48,49 Figure 2 depicts the hospitalization data. With respect to hospitalizations, there was a high level of heterogeneity with this outcome (I2 ¼ 59%) making interpretation difficult. Clifton et al.44 found that residents in the intervention group had higher rates of hospitalization (P ¼ 0.042). In the almost 5000 patients included in this metaanalysis, there was no difference in hospitalizations between intervention and control (OR 0.77 [95% CI 0.55e1.08]). For mortality (Figure 2), there were 8 studies reporting on this outcome,25,29,35,43-45,48,49 and only 7 studies had exact number of deaths in each group and therefore could be metaanalyzed.29,35,43-45,48,49 Of these studies, only Furniss et al.28 found a statistically significant change, reporting 14 deaths in the control arm compared with 4 deaths in the intervention arm at 4 months after medication review (P ¼ 0.028). Heterogeneity in the random effects model was minimal (I2 ¼ 0), reflecting the similarity in findings between studies. The pooled result is leaning toward a positive effect in favor of pharmacist intervention, showing a 9% reduction in mortality; however, this was not statistically significant (OR 0.91 [95% CI 0.79e1.05]). Falls In terms of fall reduction, of the 5 studies (19%)22,29,38,43,48 that reported this outcome, only 1 found a statistically significant change, reporting a 0.5 fall per patient reduction in favor of the intervention.43 Risk of bias The quality of studies was assessed using the Cochrane Risk of Bias v2 tool, which demonstrated that almost all studies were high risk of bias. This was primarily because of the lack of blinding that is possible with pharmacist and team-based 5
SCIENCE AND PRACTICE C.A. Sadowski et al. / Journal of the American Pharmacists Association xxx (2019) 1e9
Table 2 Results for trials reporting on the mean number of medications per patient Study
Mean number of medications/patient (unless otherwise noted)
Statistical significance Significant reduction in intervention group
King et al.24 (2001) Roberts et al25 (2001) Brulhart et al.27 (2011) Furniss et al.28 (2000)
I: 8.8-7.3 (P 0.01); C: 8.2-8.9; P 0.001 (between groups) I: 8.7-7.2 (P 0.001); C: 8.1-8.2 (P ¼ 0.84); P ¼ 0.03 (between groups) I: 0.35; C: 0.03; P ¼ 0.37 (between groups) I: 6.60; C: 7.45; P ¼ 0.15 (between groups) I: 12.8-11.8 (P < 0.01) I: 5.1-4.2; C: 4.9-4.4; P ¼ 0.07 (between groups)
Claesson et al.30 (1998) Jodar-Sanchez et al.35 (2015)
I: 7.5-7.8; C: 7.8-8.2 I: 6.4-5.9 (P < 0.001); C: 4.8-5.9 (P < 0.001)
Strikwerda et al.41 (1994)
Number of deleted drugs: I: 7%; C: 3%; P < 0.05 (between groups) I: 7.6-6.7 (P < 0.01); C: 5.9-6.1 (NS) I: prestudy year 7.9-5.7; C: prestudy year 7.2-7.1; P ¼ 0.04 between control and treatment groups after study year
Frankenthal et al.20 (2014) Frankenthal et al.21 (2017)
46
Hood et al. (1975) Thompson et al.49 (1984)
interventions, particularly when the study took place in a single facility (Appendix 2). Discussion The purpose of this study was to systematically review the literature regarding the impact of pharmacist interventions in LTC. Our study focused on 3 types of outcomes, with those being medication outcomes, clinical measures, and health system outcomes. This review found tremendous diversity in studies investigating the impact of pharmacist intervention in LTC (e.g., design, duration, and
Significant reduction in intervention group No significant difference between groups No significant difference between groups Significant reduction in intervention group No significant difference between within group changes Significance not reported Significant reduction in intervention group; significant increase in control group Significant increase in the number of deleted medications in the intervention group Significant reduction in the intervention group Significantly fewer medications in the intervention group
primary outcome measures). Pharmacist interventions were often part of a larger team-based intervention (19 of the 26 studies) and included a mixture of a few standard approaches (e.g., medication review, documentation, case conferences, and education). More than half of the studies reporting on overall medication usage found that pharmacist intervention reduced medication usage or improved medication appropriateness. Studies reporting on clinical measures and health system outcomes found few statistically significant differences; however, 8 out of 14 studies reported that pharmacist interventions reduced medication/health care costs.
Figure 2. Forest plots comparing (A) hospitalizations in intervention versus control and (B) mortality in intervention versus control.
6
SCIENCE AND PRACTICE Pharmacists’ role and impact in long-term care
With respect to cost outcomes, a systematic review by Hasan et al.52 found similar results to those reported in our study. In this study, researchers looked specifically at the cost outcomes of conducting pharmacist-led medication reviews for residents of LTC. Here, they found that 6 out of the 8 studies included in the review reported a cost benefit in favor of medication reviews.52 The studies included in our systematic review, as well as those by Hasan et al.,52 are quite heterogeneous with respect to how costs were reported and the health care systems in which they were conducted, making comparisons difficult. Our systematic review is also consistent with another review of pharmacist services in nursing homes, which reported that pharmacists improved some measures of medication appropriateness, and their interventions led to reduced falls.53 In contrast to our systematic review, this study by Lee et al., included studies with any study design, and many that did not have a control group. However, the impact that pharmacist intervention has on clinical measures and hospitalizations is less clear. There are a number of potential reasons for this, one being the short duration and small sample sizes of the included studies. Most studies were likely too short and underpowered to detect statistically significant changes in mortality, hospitalizations, and falls. The 1 study that did find increased mortality in the intervention group28 might have had this unexpected finding because of the pharmacist’s primary focus on heart failure management, rather than overall patient assessment. Another potential contributor to minimal impact on clinical outcomes was the lack of direct face-to-face interaction between the pharmacist and prescriber. The primary route of communication between the pharmacist and prescriber was often at times via indirect means (e.g., written letter), which could have contributed to some of the negative findings. The consultant role and intermittent presence of health professionals in the facilities leads to inconsistent team presence. These negative findings may spark further research regarding the types of communication that take place in this setting. For example, to maximize the impact of pharmacist services in LTC, pharmacists may have greater impact via a face-to-face conversation with the physician and nursing staff. Four of the included studies reported pharmacist recommendation acceptance rates of less than 50%, again speaking to the importance of direct communication. A systematic review by Lee et al., which looked at evaluating the effect of only medication reviews on mortality and hospitalizations in nursing home residents, was published in 2014. This review included any team structure or health professional conducting the reviews, and some studies did not even include a pharmacist. However, similar to our study, they reported that medication reviews had little effect on mortality or hospitalizations. Given the frailty and complexity of older adults, this is not surprising, as mortality is often very high in this population. In addition, there may be policies relating to hospital admissions, preventing frail older adults from unnecessary hospitalizations. Researchers found a high degree of study heterogeneity, with most studies being of overall lower quality, again echoing the findings of our study. When evaluating the lack of change seen in clinical measures, another factor that must be considered is the expanding scope of pharmacist practice that is taking place across the
world.54-56 In Canada, 2 randomized controlled trials conducted in community-dwelling patients have shown the effect that pharmacists can have when practicing at full scope (e.g., conducting risk assessments, educating patients, prescribing medications, ordering laboratory monitoring, and conducting regular follow-up visits).18,19 These studies found that pharmacists practicing at full scope can improve blood pressure and low-density lipoprotein cholesterol, 2 well-established surrogate markers.18,19 When one considers the evidence of pharmacist impact, in addition to the context of care delivery in LTC facilities, such as intermittent physician contact, or lessregulated health professionals, it is possible to see the potential benefit that a full-scope pharmacist practicing in LTC could bring. Strengths of our systematic review include its focus on LTC as a unique setting for geriatric care delivery and broad inclusion criteria (e.g., studies published in any language). To the best of our knowledge, our study is the first to investigate the impact of broader scope pharmacist interventions in LTC facilities and to conduct a meta-analysis on study outcomes. By focusing on the LTC population, we were able to help fill a gap in the medical literature, as most preexisting systematic reviews on pharmacist services have focused on services provided in the community.57 Furthermore, pharmacists’ scope of practice is expanding around the world (e.g., administering injections, prescribing).9-15 By including all types of pharmacist interventions, we were able to comprehensively evaluate the impact of pharmacist services in LTC. This is in contrast to other reviews that have focused on only medication reviews.52,53 With respect to the limitations of this review, including multiple types of pharmacist interventions and study designs made drawing focused conclusions difficult. Results must be interpreted with caution, given the lack of high-quality studies in this area.
Conclusion There is evidence to support pharmacist intervention, primarily through medication review, to reduce drug usage and improve measures in the appropriateness of medications. Overall, current evidence suggests that pharmacist interventions in LTC lead to some cost savings, through reductions in medication costs. However, further randomized controlled studies of adequate duration involving full-scope pharmacist interventions are required. In addition, these studies should include outcomes such as medication appropriateness and hospitalizations. This will help us to determine the optimal role for pharmacists in providing care in the LTC setting. Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.japh.2019.11.014 References 1. Centers for Medicare and Medicaid Services. Nursing home data compendium 2015 edition. Available at: https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/CertificationandComplianc/Downloads/ nursinghomedatacompendium_508-2015.pdf. Accessed October 11, 2019.
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2. Health at a Glance 2017. Recipients of long-term care. Available at: https://www.oecd-ilibrary.org/social-issues-migration-health/health-ata-glance-2017/recipients-of-long-term-care_health_glance-2017-77-en. Accessed March 25, 2018. 3. Schram MT, Frijters D, van de Lisdonk EH, et al. Setting and registry characteristics affect the prevalence and nature of multimorbidity in the elderly. J Clin Epidemiol. 2008;61(11):1104e1112. 4. Jokanovic N, Tan EC, Dooley MJ, Kirkpatrick CM, Bell JS. Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review. J Am Med Dir Assoc. 2015;16(6): 535.e1e535.e12. 5. De Silva TR, Theou O, Vellas B, Cesari M, Visvanathan R. Frailty Screening (FRAIL-NH) and mortality in French nursing homes: results from the incidence of pneumonia and related consequences in nursing home residents study. J Am Med Dir Assoc. 2018;19(5):411e414. 6. Rockwood K, Stolee P, McDowell I. Factors associated with institutionalization of older people in Canada: testing a multifactorial definition of frailty. J Am Geriatr Soc. 1996;44(5):578e582. 7. Tam SHY, Hirsch JD, Watanabe JH. Medication regimen complexity in long-term care facilities and adverse drug events-related hospitalizations. Consult Pharm. 2017;32(5):281e284. 8. Latter S, Blenkinsopp A. Non-medical prescribing: current and future contribution of pharmacists and nurses. Int J Pharm Pract. 2011;19(6): 381e382. 9. Pharmaceutical Society of New Zealand Incorporated. New Zealand National Pharmacist Services Framework 2014. Available at: https://www.psnz.org. nz/Folder?Action¼View%20File&Folder_id¼86&File¼PSNZPharmacist ServicesFramework2014FINAL.pdf. Accessed October 21, 2019. 10. American College of Clinical Pharmacy, McBane SE, Dopp AL, et al. Collaborative drug therapy management by and comprehensive medication management-2015. Pharmacotherapy. 2015;35(4):e39ee50. 11. Canadian Pharmacists Association. Pharmacists’ scope of practice in Canada. Available at: https://www.pharmacists.ca/cpha-ca/assets/File/ cpha-on-the-issues/ScopeofPracticeinCanada_DEC2016.pdf. Accessed March 25, 2018. 12. The Pharmaceutical Society of Ireland. Seasonal influenza vaccination programme in pharmacies evidence base and framework. Available at: http://www.lenus.ie/hse/handle/10147/234069. Accessed October 21, 2019. 13. Francis M, Hinchliffe A. Vaccination services through community pharmacy: a literature review. Available at: http://www2.nphs.wales.nhs. uk:8080/HealthServiceQDTDocs.nsf/public/CBDDC3C0BE94493980257 93B00341A6F/$file/Vaccination%20services%20through%20community %20pharmacy%20v1a.pdf. Accessed February 26, 2013. 14. 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. Arch Intern Med. 2011;171(16):1441e1453. 15. Tan EC, Stewart K, Elliott RA, George J. Pharmacist services provided in general practice clinics: a systematic review and meta-analysis. Res Social Adm Pharm. 2014;10(4):608e622. 16. Hughes CA, Breault RR, Hicks D, Schindel TJ. Positioning pharmacists’ roles in primary health care: a discourse analysis of the compensation plan in Alberta, Canada. BMC Health Serv Res. 2017;17(1):770. 17. Houle SK, Grindrod KA, Chatterley T, Tsuyuki RT. Paying pharmacists for patient care: a systematic review of remunerated pharmacy clinical care services. Can Pharm J (Ott). 2014;147(4):209e232. 18. Tsuyuki RT, Houle SK, Charrois TL, 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(2):93e100. 19. Tsuyuki RT, Rosenthal M, Pearson GJ. A randomized trial of a communitybased approach to dyslipidemia management: pharmacist prescribing to achieve cholesterol targets (RxACT study). Can Pharm J (Ott). 2016;149(5):283e292. 20. Frankenthal D, Lerman Y, Kalendaryev E, Lerman Y. Intervention with the screening tool of older persons potentially inappropriate prescriptions/ screening tool to alert doctors to right treatment criteria in elderly residents of a chronic geriatric facility: a randomized clinical trial. J Am Geriatr Soc. 2014;62(9):1658e1665. 21. Frankenthal D, Israeli A, Caraco Y, et al. Long-term outcomes of medication intervention using the screening tool of older persons potentially inappropriate prescriptions screening tool to alert doctors to right treatment criteria. J Am Geriatr Soc. 2017;65(2):e33ee38. 22. Crotty M, Whitehead C, Rowett D, et al. An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial [ISRCTN67855475]. BMC Health Serv Res. 2004;4(6):1e6. 23. Crotty M, Halbert J, Rowett D, et al. An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing. Age Ageing. 2004;33(6):612e617.
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24. King MA, Roberts MS. Multidisciplinary case conference reviews: improving outcomes for nursing home residents, carers and health professionals. Pharm World Sci. 2001;23(2):41e45. 25. Roberts MS, Stokes JA, King MA, et al. Outcomes of a randomized controlled trial of a clinical pharmacy intervention in 52 nursing homes. Br J Clin Pharmacol. 2001;51(3):257e265. 26. Westbury J, Jackson S, Gee P, Peterson G. An effective approach to decrease antipsychotic and benzodiazepine use in nursing homes: the RedUSe project. Int Psychogeriatr. 2010;22(1):26e36. 27. Brulhart MI, Wermeille JP. Multidisciplinary medication review: evaluation of a pharmaceutical care model for nursing homes. Int J Clin Pharm. 2011;33(3):549e557. 28. Furniss L, Burns A, Craig SK, Scobie S, Cooke J, Faragher B. Effects of a pharmacist’s medication review in nursing homes. Randomised controlled trial. Br J Psychiatry. 2000;176(6):563e567. 29. Burns A, Furniss L, Cooke J, Lloyd Craig SK, Scobie S. Pharmacist medication review in nursing homes: a cost analysis. Int J Geriatr Psychopharmacol. 2000;2(3):137e141. 30. Claesson CB, Schmidt IK. Drug use in Swedish nursing homes. Clin Drug Investig. 1998;16(6):441e452. 31. Schmidt I, Claesson CB, Westerholm B, Nilsson LG, Svarstad BL. The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. J Am Geriatr Soc. 1998;46(1): 77e82. 32. Schmidt IK, Claesson CB, Westerholm B, Nilsson LG. Physician and staff assessments of drug interventions and outcomes in Swedish nursing homes. Ann Pharmacother. 1998;32(1):27e32. 33. da Costa FA, Silvestre L, Periquito C, et al. Drug-related problems identified in a sample of Portuguese institutionalised elderly patients and pharmacists’ interventions to improve safety and effectiveness of medicines. Drugs Real World Outcomes. 2016;3(1):89e97. 34. Eide E, Schjøtt J. Assessing the effects of an intervention by a pharmacist on prescribing and administration of hypnotics in nursing homes. Pharm World Sci. 2001;23(6):227e231. dar-S pez del Amo MP, García L, Araújo-Santos JM, 35. Jo anchez F, Martín JJ, Lo Epstein D. Cost-utility analysis of a pharmacotherapy follow-up for elderly nursing home residents in Spain. J Am Geriatr Soc. 2014;62(7): 1272e1280. 36. Kersten H, Molden E, Tolo IK, Skovlund E, Engedal K, Wyller TB. Cognitive effects of reducing anticholinergic drug burden in a frail elderly population: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2013;68(3):271e278. € v P, Bondesson A, Eriksson T, Petersson J, Minthon L, Ho € glund P. 37. Midlo Descriptive study and pharmacotherapeutic intervention in patients with epilepsy or Parkinson’s disease at nursing homes in southern Sweden. Eur J Clin Pharmacol. 2002;57(12):903e910. 38. Patterson SM, Hughes CM, Crealey G, Cardwell C, Lapane KL. An evaluation of an adapted U.S. model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood Northern Ireland Study). J Am Geriatr Soc. 2010;58(1):44e53. 39. Patterson SM, Hughes CM, Cardwell C, Lapane KL, Murray AM, Crealey GE. A cluster randomized controlled trial of an adapted U.S. model of pharmaceutical care for nursing home residents in Northern Ireland (Fleetwood Northern Ireland Study): a cost-effectiveness analysis. J Am Geriatr Soc. 2011;59(4):586e593. 40. Patterson SM, Crealey G, Lapane KL, Hughes CM. Description of interventions performed during the Fleetwood Northern Ireland Study. J Appl Ther Res. 2010;7(3):101e109. 41. Strikwerda P, Bootsma-de Langen AM, Berghuis F, Meyboom-de Jong B. [Drug therapy in a nursing home; favorable effect of feedback by the pharmacist on family physician's prescribing behavior]. Ned Tijdschr Geneeskd. 1994;138(35):1770e1774. 42. Verrue C, Mehuys E, Boussery K, Adriaens E, Remon JP, Petrovic M. A pharmacist-conducted medication review in nursing home residents: impact on the appropriateness of prescribing. Acta Clin Belg. 2012;67(6): 423e429. 43. Zermansky AG, Alldred DP, Petty DR, et al. Clinical medication review by a pharmacist of elderly people living in care homes–randomised controlled trial. Age Ageing. 2006;35(6):586e591. 44. Clifton GD, Ranz TT, Blumenschein K, Lehman ME. Heart failure guideline use in long term care facilities: consultant pharmacist initiated approach to improve awareness. Consult Pharm. 2000;15(6):623e630. 45. Cooper JW, Wade WE. Pharmacist interventions in geriatric nursing facility NSAID therapy: a one-year follow-up study of costs and outcomes. Consult Pharm. 2005;20(6):492e497. 46. Hood JC, Lemberger M, Stewart RB. Promoting appropriate therapy in a long-term care facility. J Am Health Care Assoc. 1975;1(2):10e13. 47. Horning KK, Hoehns JD, Doucette WR. Adherence to clinical practice guidelines for 7 chronic conditions in long-term-care patients who
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54. Ramalho de Oliveira D, Brummel AR, Miller DB. Medication therapy management: 10 years of experience in a large integrated health care system. J Manag Care Pharm. 2010;16(3):185e195. 55. Manolakis PG, Skelton JB. Pharmacists’ contributions to primary care in the United States collaborating to address unmet patient care needs: the emerging role for pharmacists to address the shortage of primary care providers. Am J Pharm Educ. 2010;74(10):S7. 56. Agomo CO. The role of community pharmacists in public health: a scoping review of the literature. J Pharm Health Serv Res. 2012;3(1):25e33. 57. Jokanovic N, Tan EC, Sudhakaran S, et al. Pharmacist-led medication review in community settings: an overview of systematic reviews. Res Social Adm Pharm. 2017;13(4):661e685. Cheryl A. Sadowski, BSc(Pharm), PharmD, BCGP, FCSHP, Professor, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, AB Theresa L. Charrois, BScPharm, ACPR, MSc, Clinical Associate Professor, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB Evan Sehn, BScPharm, PharmD, Clinical Pharmacist, Sobeys Inc, Lethbridge, AB Trish Chatterley, BA, MLIS, Collection Strategies Coordinator, University of Alberta, Edmonton, AB Sujin Kim, BScPharm, Clinical Pharmacist, Rite Aid Pharmacy, Federal Way, WA
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Appendix 1. Search strategy
1. 2. 3. 4.
drug information services/ or medication therapy management/ "drug utilization review"/ Pharmaceutical Services/ ((drug or medication or medicine* or prescription*) adj2 (manag* or therapy or review* or audit* or consult* or monitor* or screen* or counsel* or recommend*)).ti,ab. 5. (prescription adaptation or therapeutic substitution or prescription renewal*).mp. 6. pharmaceutical case management.mp. 7. (pharmaceutical care or disease state management).mp. 8. (pharmacist$ adj2 (prescribe or prescribes or prescribing)).mp. 9. ((independent or supplementary or nonmedical or non-medical or repeat or collaborative) adj prescrib$).mp. 10. (pharmaceutical opinion* or "refusal to dispense" or "refusal to fill").mp. 11. (pharmacist* adj4 intervention*).mp. 12. (cognitive adj2 service*).mp. 13. clinical pharmac*.mp. 14. "Referral and consultation"/ 15. Directive Counseling/ or counseling/ 16. "utilization review"/ or "concurrent review"/ 17. Patient education as topic/ 18. patient care management/ or case management/ 19. follow-up.mp. 20. (clinical adj2 (care or service*)).mp. 21. (educat* or counsel* or consult*).mp. 22. academic detailing.mp. 23. or/1-22 24. Pharmacists/ or exp pharmaceutical services/ 25. pharmacist*.mp. 26. 24 or 25 27. 23 and 26 28. Homes for the aged/ 29. residential facilities/ or assisted living facilities/ or group homes/ or exp nursing homes/ 30. (nursing adj2 (home*1 or unit*1 or center*1 or centre*1)).ti,ab. 31. (group adj2 home*).ti,ab. 32. (long-term care adj2 facilit*).ti,ab. 33. (care adj2 (home* or facilit*)).ti,ab. 34. (rest adj2 home*).ti,ab. 35. (residential adj2 (home* or care)).ti,ab. 36. (geriatric adj2 (home* or unit* or facilit* or institution*)).ti,ab. 37. Long-Term care/ 38. ((long-term or longterm or continuing) adj2 care).ti,ab. 39. ((supportive or assisted or institutional) adj2 living).ti,ab. 40. Institutionalization/ 41. or/29-40 42. exp aged/ 43. (aged or old people or older people or old persons or older persons or old resident* or older resident* or elders or elderly or geriatric or senior*).ti,ab. 44. 42 or 43 45. 41 and 44 46. 28 or 45 47. clinical trial/ or controlled clinical trial/ or multicenter study/ or randomized controlled trial/ or comparative study/ or meta-analysis/ 48. Intervention studies/ 49. Double-Blind method/ 50. random*.ti,ab. 51. trial.ti,ab. or trials.ti. 52. (systematic* adj2 (review* or search*)).mp. 53. meta-analy*.mp. 54. review.pt. 55. or/47-54 56. 27 and 46 and 55
9.e1
SCIENCE AND PRACTICE Pharmacists’ role and impact in long-term care
Appendix 2. Risk of bias
No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
World region Asia Frankenthal et al.20 (2014), Israel Frankenthal et al.21 (2017), Israel Australia Crotty et al.22 (2004a) Crotty et al.23 (2004b) King et al.24 (2001) Roberts et al.25 (2001) Westbury et al.26 (2009) Europe Brulhart et al.27 (2011), Switzerland Burns et al.28 (2000), Furniss et al.29 (2000), United Kingdom Claesson et al.30 (1998), Schmidt et al.31,32 (1998a, 1998b), Sweden Da Costa et al.33 (2016), Portugal Eide et al.34 (2001), Norway Jodar-Sanchez et al.35 (2014), Spain Kersten et al.36 (2013), Norway Midlov et al.37 (2002), Sweden Patterson et al.38-40 (2010a, 2010b, 2011), United Kingdom Strikwerda et al.41 (1994), the Netherlands Verrue et al.42 (2012), Belgium Zermansky et al.43 (2006), United Kingdom United States Clifton et al.44 (2000) Cooper et al.45 (2005) Hood et al.46 (1975) Horning et al.47 (2007) Lapane et al.48 (2011) Thompson et al.49 (1984) Trygstad et al.50,51 (2005, 2009)
Risk of bias Some concerns Some concerns High High High High High
risk risk risk risk risk
of of of of of
bias bias bias bias bias
Some concerns High risk of bias High risk of bias High risk of bias High risk of bias High risk of bias Some concerns Some concerns High risk of bias High risk of bias High risk of bias Some concerns High High High High High High High
risk risk risk risk risk risk risk
of of of of of of of
bias bias bias bias bias bias bias
9.e2