Tools to prioritize outpatients for pharmaceutical service: A scoping review

Journal Pre-proof Tools to prioritize outpatients for pharmaceutical service: A scoping review Maria do Carmo Vilas-Bôas Sousa, Brígida Dias Fernandes, Aline Aparecida Foppa, Paulo Henrique Ribeiro Fernandes Almeida, Simone de Araújo Medina Mendonça, Clarice Chemello PII:

S1551-7411(19)31055-1

DOI:

https://doi.org/10.1016/j.sapharm.2020.02.010

Reference:

RSAP 1454

To appear in:

Research in Social & Administrative Pharmacy

Received Date: 1 November 2019 Revised Date:

7 February 2020

Accepted Date: 18 February 2020

Please cite this article as: Sousa Maria.do.Carmo.Vilas.-Bô., Fernandes Brí.Dias., Foppa AA, Almeida PHRF, Mendonça Simone.de.Araú.Medina., Chemello C, Tools to prioritize outpatients for pharmaceutical service: A scoping review, Research in Social & Administrative Pharmacy (2020), doi: https://doi.org/10.1016/j.sapharm.2020.02.010. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.

Tools to prioritize outpatients for pharmaceutical service: a scoping review Maria do Carmo Vilas-Bôas Sousa*, Brígida Dias Fernandes, Aline Aparecida Foppa, Paulo Henrique Ribeiro Fernandes Almeida, Simone de Araújo Medina Mendonça, Clarice Chemello. a

Faculty of Pharmacy, Federal University of Minas Gerais, Av. Presidente Antônio

Carlos, 6627, Pampulha, Belo Horizonte, Minas Gerais, 31.270-901, Brazil. * Corresponding author: [email protected]

1

Background: The performance of pharmacists in clinical services contributes to

2

improving outcomes in patient drug therapy. In the context of streamlined resources and

3

high health services’ demand, the use of patient selection tools can screen those who

4

would benefit more from a pharmaceutical service. Objective: This review aims to map

5

and describe tools developed for patient selection for pharmaceutical services delivered

6

in primary health care and outpatient settings. Methods: The search was conducted in

7

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and the Latin

8

American and Caribbean Health Sciences. The search strategy included terms relating to

9

patient selection and outpatient pharmaceutical service. We included papers on

10

outpatient settings, and which described the tool developed for the selection of a patient

11

for pharmaceutical service. Two reviewers extracted data of each study concerning the

12

types and items making up the tool. The items composing the tools were grouped into

13

categories. Results: Twelve studies were included in the literature. Most of the studies

14

were developed in the United States (53.8%), followed by Canada (30.8%).

15

Approximately half of the studies developed tools for selecting patients for a medication

16

review (46.2%), and only 15.4% for drug therapy management. Identification of

17

patients at risk of drug-related problems, the need for pharmaceutical service follow-up,

18

and patients at risk of hospital readmission were the main objective to develop the tools.

19

In total, 92.3% of the developed tools had items related to drug therapy complexity,

20

76.9% to comorbidities and 61.5% to adherence/subjective aspects. Statistical methods

21

were employed to evaluate the validation parameters, such as the ROC curve and

22

internal consistency.

23

Conclusions: Few studies that developed tools to select outpatients for pharmaceutical

24

services were found. However, many tools showed unsatisfactory validation parameters.

25

Thus, it is necessary to improve the development of instruments that can identify

26

patients who would benefit from the pharmaceutical service accurately.

26

Keywords: Patient selection; Pharmaceutical care; Pharmaceutical services; Risk Assessment;

27

Primary Health Care; Outpatient.

28 29

INTRODUCTION

30

Pharmacists are in a unique position to provide clinical services, improve outcomes, and enhance

31

patients’ pharmacotherapeutic capabilities. Such services provide outcomes favorable to health

32

care and medication use in primary and outpatient care patients1-2.

33

The care process should focus on the needs of the patient and streamline the medication use-

34

related results. The pharmacist’s knowledge, skill, and experience should be present throughout

35

the process to achieve satisfactory outcomes in patient drug therapy3-4. Therefore, it is crucial to

36

adopt a uniform and structured patient follow-up process and raise the quality of the service

37

provided, so that expectations are shared and accepted with responsibility5. Thus, the care

38

process must be consistent and reproducible for the patients, caregivers, and health professionals,

39

so that they can view the clinical pharmacist’s contribution in improving medication-related

40

outcomes4.

41

The development and implementation of a treatment model for patients in all health systems

42

remain challenging1,6, especially the organization of the pharmaceutical care work process that

43

allows the care of all patients requiring pharmacotherapeutic follow-up. Because of the increased

44

demand in health services, resource rationalization and care coordination streamlining, the

45

availability of tools allowing selection of patients that would most benefit from the

46

pharmaceutical service becomes indispensable7-8.

47

The use of instruments to select patients contributes to directing care to those who would most

48

benefit from pharmaceutical services. Thus, the referral of patients who have greater needs

49

collaborates with drug therapy streamlining, improved clinical conditions, and higher levels of

50

patient’s empowerment with self-care, which directly influence the quality of life and reduce

51

health expenditure1,9,10-11.

52

In this context, tools have been developed in several professional areas for patient screening and

53

prioritization for health care12-13, as nursing13,14, psychology15,16, medicine17,18. In pharmaceutical

54

practice, the use of clinical and pharmacotherapeutic criteria for the selection of patients is

55

established empirically, according to the health professional experience, clinical condition

56

patients and characteristics of health services19-20. It is known that patient prioritization tools were

57

developed and reviewed21 in the hospital setting. However, a comprehensive review of the tools

58

developed for patient selection for pharmaceutical care in primary and outpatient care has not

59

been performed to date.

60

Thus, this scoping review aimed to identify and describe the tools developed for patient selection

61

for pharmaceutical services delivered in primary and outpatient settings.

62 63

METHODS

64

This scoping review was performed to understand conceptions that underpin a research area,

65

explain work definitions or theoretical limits on a topic22. This review follows the Preferred

66

Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

67

(PRISMA-ScR)

68

(https://osf.io/a42yb/).

69

Databases and search strategy

70

The search for relevant studies was carried out in April 2019, on the following search databases:

71

MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL),

72

and the Latin American and Caribbean Health Sciences (LILACS). The search strategy included

73

terms relating to population, concept, and context (PCC) (The Joanna Briggs Institute, 2017)22:

74

outpatients, tools to patient selection for pharmaceutical service, and primary health

75

care/ambulatory, respectively (Appendix 1). As a complement to the electronic search, a manual

76

search was carried out in the references of the selected studies and systematic reviews, as well as

77

Clinical Trials. Studies in gray literature in the Digital Library of the Federal University of Minas

78

Gerais (UFMG), and the thesis and dissertations bank of the Coordination of Improvement of

79

Personnel of Higher Education (CAPES), and the Brazilian Digital Library of Theses and

80

Dissertations, were also searched.

81

Selection of Studies and Eligibility Criteria

and

the

review

protocol

registered

on

Open

Science

Framework

82

Randomized Clinical Trial (RCT), quasi-experimental, and observational studies (cross-sectional,

83

cohort studies, or pragmatic studies) that developed a tool to select a patient for pharmaceutical

84

services in primary health care and outpatient settings were included in this review. In this

85

review, we consider family medicine clinic, ambulatories and community pharmacies as primary

86

and outpatients settings23.

87

Review papers, editorials, comments, and qualitative studies; studies with inpatients in other

88

services (nursing home, hospital), transcultural studies, and studies without a tool description

89

were excluded.

90

Data collection and analysis

91

Initially, a unified database was created with the publications retrieved by the strategy. Then,

92

duplicates were removed using EndNote software. Next, a team of independent reviewers (MC,

93

BD, and AF) evaluated the titles (Phase 1), abstracts (Phase 2), and full-texts (Phase 3). Any

94

disagreements were resolved again by consensus among the reviewers. This process was

95

performed using Rayyan, a Web application designed to assist in this step of the systematic

96

review (identification, screening, eligibility, and inclusion)24.

97

The study characteristics (author, year of publication, country, study type, sample type and size,

98

study duration), context (setting, type of pharmaceutical service involved in the application of the

99

instrument) and tool features (application type, number of items for each tool, answer type, item

100

development, tool composition, instrument application and evidence of validity) were collected.

101

Two investigators (MC and BD) extracted data from the studies. Inconsistencies or disagreements

102

were resolved by consensus among the reviewers (SM). The tools’ items were grouped and coded

103

under different categories.

104

The included studies were submitted to a descriptive synthesis, which refers to the summarization

105

of the data collected from the studies included. The studies were grouped by method design type,

106

along with outcome measures and publication characteristics.

107

A methodological quality assessment of the included studies was not performed, as the review

108

was not intended to gather evidence on which tools are most effective for patient selection. The

109

objective was to identify existing tools and highlight their main characteristics, as recommended

110

by PRISMA-ScR, and performed in other scope reviews25-26.

111 112

RESULTS

113

The search platforms returned about 5,501 publications (Figure 1). In total, 27 publications were

114

selected for full-text reading (phase 3) after removing duplicates and reading titles and abstracts

115

(Phase 1 and Phase 2). Most full-text publications were excluded by type of design or because the

116

instrument developed was not for patient selection for pharmaceutical services. A manual search

117

of the reference lists of the papers selected three other publications27-28. In the end, thirteen

118

studies were included.

Identification

Records identified through database search PubMed (n=2,338) Embase (n=1,194) Cochrane (n=1,941) LILACS (n=28) Total (n=5,501)

Screening

Full-text papers assessed for eligibility (n=27)

Included

Titles and abstracts screened (after duplicate removal) (n=5,133)

Eligibility

Duplicates excluded (n=368)

119 120

Excluded (n=5,106) Study design (n=4,952) Instruments not for patient selection (n=149) Inpatient instruments (n=5)

Excluded (n=18) Study design (n=11) Inpatient instruments (n=6) Full-text not available (n=1) 4 additional papers/reports identified through a manual search

Papers included in the review (n=13)

Figure 1 - Flowchart of study selection and inclusion process.

121 122

Characteristics of the studies included

123

Table 1 summarizes the characteristics of the studies included. Four studies were cross-sectional

124

(30.8%), and four were retrospective and prospective cohort (30.8%). The country with most

125

studies was the U.S. (n=7; 53.8%), followed by Canada (n=3; 30.8%). Concerning the tool

126

application’s context, 30.8% (n=4) of the studies were conducted in primary care/family

127

medicine clinics. Studies had a mean duration of four months. Approximately half of the studies

128

were about developed tools for the selection of patients for medication review (MR) (n=6;

129

46.2%) and only 15.4% (n=2), medication therapy management (MTM). Also, the type of

130

pharmaceutical service was unclear in three studies (23.1%).

131

Concerning the approach used to select patients who would require pharmaceutical services,

132

Crutzen et al.29 and Rofu et al.30 evaluated the complexity of the patient’s clinical situation and

133

drug therapy to reduce hospital readmission. Awad et al.31, Ploenzke et al.32 and Doucette et al.27

134

developed tools to prioritize patients who could benefit from a clinical pharmacy service. Griend

135

et al.33, Snyder et al.34, Levy35, and the other studies36,28,37,38 aimed to identify patients with a

136

higher risk for developing a Drug Related Problem (DRP). Finally, the tools elaborated by

137

Makowsky, Cave, and Simpson37, Langford et al.36, Isaksen et al.28, and Pammett et al.39 were

138

based on tools published in others studies36,35,40. Some tools were developed for populations with

139

specific characteristics. Covert et al.38 developed an instrument for renal transplant patients and

140

Awad et al.31, a tool targeting HIV-positive patients, while tools developed by Crutzen et al.29,

141

Levy35 and Doucette et al.27 concerned elderly patients.

Table 1: Characteristics of studies included in the scoping review (n=13). Author, year (Country)

Objective

Awad et al., 201731

To create a scoring system allowing

(Canada)

for standardized prioritization of pharmacist

consults

Study design

for

patients

Setting

Duration

Sample

Pharmaceutical

size

service involved* Clinical pharmacy

Cohort

HIV outpatient clinic

6 months

200

living with HIV.

service (pharmacist consult)

Covert et al., 201638

To develop a model to predict which

(United States)

patients are at the highest risk of DRP to streamline pharmacists' workflow

Cohort

Renal transplant clinic

3 months

237

MR

Not reported

166

MR

Not reported

225

CMR

in a chronic kidney transplant clinic. To develop and pilot an algorithm to 29

Crutzen et al., 2019 (Netherlands)

select older people for different types

Cross-

Community

of MR based on the patient’s case

sectional

pharmacy

complexity. Doucette et al., 201327

To develop and assess a patient

(United States)

medication user self-evaluation tool

Cross-

to identify Medicare beneficiaries

sectional

Ambulatory

who would benefit from a CMR. Isaksen et al., 199928 (United States)

To

validate

a

computer-based

program to identify patients at high risk for DRP.

Unclear Unclear

Ambulatory

Not reported

246

Langford et al., 200636 (Canada)

To determine if a self-administered questionnaire

can

improve

the

identification of patients at risk for DRP compared with usual methods of referral to a pharmacist. Levy, 200335 (United States)

Prospective, randomized

Family

controlled

medicine clinic

2 months

194

Unclear

Not reported

40

MR

8 months

100

Unclear

4 months

49

CMA

5 months

31

MTM

study

To evaluate and validate a screening tool for the elderly as a means to identify patients who might be at

Cohort

Community pharmacy

increased risk for DRP. Makowsky, Cave,

To test the feasibility of a self-

Simpson, 201437

administered

(Canada)

patient

survey,

to

facilitate the identification of patients

Cross-

Family

sectional

medicine clinic

at high risk of DRP. Pammett et al., 201539 (Canada)

To

determine

the

capacity

of

screening questionnaire to identify

Unclear

patients at risk for DRP. Ploenzke et al., 201632 (United States)

Community pharmacy

To improve patient care through the development

of

a

clinical

risk

stratification tool to identify high-risk patients

and

implementation

pharmacist-mediated management

after

of

medication patient

care

Quasi-

Primary care

experimental

clinics

transitions. Rofu et al., 201830

To validate a risk-stratification tool to

(Australia)

identify low-risk patients in whom a telephone MR would be a safe and

Cohort

Patient's home

Cross-

Community

sectional

pharmacy

11 months

235

HOMR

8 months

594

MTM

3 months

1107

CMR

effective alternative to a home-based review. Snyder et al., 201534 (United States)

To

estimate

the

psychometric

properties of a brief self-administered scale as a screening tool for DRP.

Griend et al., 201533

To develop a tool that would identify

(United States)

patients in a family medicine clinic who are more likely to have DRP and

Unclear

Family medicine clinic

prioritize them for CMR.

DRP: Drug-Related Problems; CMA: Comprehensive Medication Assessment; CMR: Comprehensive Medication Review; MTM: Medication Therapy Management; HOMR: Hospital Outreach Medication Review; HIV: Human Immunodeficiency Virus; MR: Medication Review. * Although the terminology of pharmaceutical services is not standardized between different studies, we opt to use the terms as described in the papers, because, each country adopts the consensus/guidelines that best adapts to its health reality.

139

Characteristics of the tools developed

140

The type of tool application most used in the studies was self-administration (n=8; 61.5%),

141

followed by the application by the pharmacist (n=3; 23.1%) (Table 2). The mean number of the

142

instrument’s content items was 9.2, with a minimum number of four, and a maximum of

143

eighteen. In 53.8% (n=7) of the studies, individuals were selected and referred to the clinical

144

pharmaceutical service, and in other studies, the tool was only developed.

145

The majority of the tools had a “yes/no” response to items composing the tools (n=7; 53.8%).

146

The answer of type Likert scale and points for each item was found in 23.1% (n=3) of the studies.

147

Literature review, consensus among researchers, panel of experts, and others were the main

148

processes to develop the tools. Three or more yes responses and/or criteria were related to high

149

risk for DRP in 38.5% (n=5). Various statistical methods were employed to identify the main

150

factors that interfere with the patient’s need for a pharmaceutical service and the reasons

151

associated with the increased risk of developing DRP in patients. Also, the statistical evaluation

152

of the data obtained by applying the tools is an important step in the validation procedure. Thus,

153

30.8% (n=4) of the studies calculated the area under the ROC curve, sensitivity and

154

specificity28,30,34,38, 15.4% (n=2), the internal consistency34,35, and 23.1% (n=3) did not perform

155

any statistical test to assess the validity of the tools36,32,37. Only Snyder et al. (2015)34 used

156

psychometric parameters to validate the tool, among the tests highlighted were the factor

157

analysis, the area under the ROC curve, internal consistency, and others.

Table 2: Characteristics of the tools developed in the studies (n=13). Author,

Tool

Application

Answer

Number

Target

year

name

type

type

of items

population

Tool cut-off

Procedures for developing items

Validation procedures

Scoring system

Awad et al., 31

2017

Patients

Interviewed None

by

Yes/No

18

pharmacist

living with HIV (≥18 years)

for urgency to care (<48 h; <1 month; < 3 months; no consult

Database; panels of experts using a modified Delphi

ROC; ICC; ordinal regression*

method

required) Yes/No; Covert et 38

al., 2016

None

Self-

Likert 4

administered

or 5

9

29

al., 2019

Doucette et al., 201327

None

MUSE

Selfadministered

Self‐ administered

Points for each

4

item

Yes/No; openended

transplant

Not described

recipients

points

Crutzen et

Literature review;

Kidney

7

consensus among

AUC = 0.720 (95% CI: 0.627-0.814);

study

sensitivity = 62.5%; specificity = 66.7%.

investigators Minimum score

Four criteria significantly predicted the

was eight. The

complexity rating (p<0.0001; adjusted R-

Older people

maximum score

(≥65 years

depends on the

and with ≥5

number of

medications)

medications and

Panels of experts using a modified Delphi method

square = 0.73). Kappa values for the agreement of the algorithm score with the community pharmacists 'and experts' ratings on the complexity from 0.13 to 0.55 and on

prescribers a

the need for a medication review at different

patient have.

cut-off points ranged from 0.052 to 0.32.

Older people

Low, moderate

Literature review;

All items were statistically significant

(≥65 years);

and high benefit

consensus among

(p<0.05), except the number of pharmacies

continuous

from a CMR (no

study

and number of hospitalizations in the past 6

questions

use of

describe the

investigators;

months. Improvement of prediction accuracy

medicines

values)

survey with

of the model, increasing the AIC (data not

patients and

reported)

pharmacists Sensitivity for each of the six criteria ranges Patients had at least one

Yes/No; Isaksen et al., 199928

None

Database

categoric al

prescription 6

dispensed within the preceding 12

from 60.4% to 91.7%, and specificity ranged Three or more

Literature review

criteria indicate

(Based on

patients with

Koecheler et al.,

risk to DRP

1989)

months

from 61.1% to 97.1%. When compared with the medical record, the computer program had a sensitivity of 65.7% and a specificity of 88.2% for detecting patients classified as high risk for DRPs. Kappa statistics ranged from 0.38-0.83, and the Spearman correlation ranged from 0.63-0.91.

Adults (≥18 Langford et al., 200636

None

Self‐

Yes/No

administered

5

years and with ≥2 medications)

Three or more yes responses

Literature review

indicate patients

(Based on Levy,

with risk to

2003)

None

DRP Inter-rater reliability was 0.847. Individual

Likert 5 Levy, 35

2003

None

Self‐

points

administered

10

Older people

Three or more

(≥65 years

criteria indicate

and with ≥2

patients with

medications)

risk to DRP

questions matched well between the Literature review

investigator and participants (κ: 0.4–0.6 for 3 questions; >0.6 for 6 questions). Test-retest reliability was significant (κ> 0.6). Internal consistency= 0.69.

Makowsky, Cave,

None

Self‐ administered

Yes/No

10

Adults (≥18

Three or more

Literature review

years)

criteria indicate

(Based on

None

Simpson, 37

2014

patients with

Langford et al.,

risk to DRP

2006; Levy, 2003) Three of the five questions had high levels of

Adults (≥18

Pammett et al., 201539

MRAQ

Self‐ administered

Yes/No

5

years) and no

Three or more

change in the

criteria indicate

prescription

patients with

in last 6

risk to DRP

interrater agreement (κ: 0.877, 0.836, and Literature review

0.912), While the others had low levels of

(Based on Levy,

agreement (κ: 0.422, and 0.489). The

2003)

agreement between risk classification based on the questionnaire and medication

months

Ploenzke et al., 201632

CCTS

Interviewed

Points

by

for each

pharmacist

item

assessment was excellent (κ: 0.91, p<0.01). Guidelines;

Post16

discharge patients in

literature review; Not described

consensus among

None

study

seven days

investigators Cut-off value of the risk score to predict 90-

Rofu et al., 201830

None

Interviewed

Points

by

for each

pharmacist

item

Patients with 14

General

high-risk (score > 10) and low risk (score ≤ 10)

day hospital readmission was 11 Risk stratification

(sensitivity=50%, specificity=79%, positive

guidelines; panels

predictive=32%, negative predictive=89%.),

of experts

and the cut-off score of 10 resulted in a sensitivity of 55% and specificity of 73%. AUC=0.64 (p=0.02).

Snyder et al., 201534

None

Selfadministered

Likert 5 points

9

Adults (≥18

Questionnaire;

This represented 38% of the variance.

years) and

consensus among

Cronbach's alpha was 0.79 in phase 1 and 0.82

study

in phase 2. In CFA, item loadings ranged from

least one

investigators; item

0.33 to 0.80, and all loaded significantly

prescription

pool administered

(p<0.001). The chi-squared test was

taking at

Not described

medication

to a sample of

significant (102.69, 27 df, p<0.001), the

for a chronic

adults

comparative fit index was 0.86, and the

condition

RMSEA was 0.12. AUC=0.78 (p=0.001; 95% CI: 0.66-0.90). The scale shows an approximate sensitivity of 81-86% and specificity of 61%. Compared with CP2 scores in level 1, patient appointments were more likely to receive a pharmacist intervention after comprehensive

Score ranged

Griend et 33

al., 2015

from 0 to 21

Points CP2

Database

for each item

6

General

points divided in four levels (Level 1, 2, 3 and 4)

EHR; consensus among study investigators

medication review in level 2 (RR: 30.4; 95% CI: 7.4–125.3), in level 3 (RR: 98.8; 95% CI: 24.2–403.3), and in level 4 (RR: 154; 95% CI: 37.5–632.8). The odds of a patient appointment receiving intervention by a pharmacist after CMR grew with increasing CP2 score (p< 0.0001).

AUC: Area under the ROC curve; AIC: Akaike Information Criterion; CCTS: Composite Care Transition Score; CFA: Confirmatory Factor Analysis; CI: Confidence interval; CMR: Comprehensive Medication Review; CP2: Clinical Pharmacy Priority Score; DRP: Drug-Related Problems; EHR: Electronic Health Record; ICC: Intraclass Correlation Coefficient; KR20: Kuder–Richardson Formula 20; MRP: Medication-Related Problems; MRAQ: Medication Risk Assessment Questionnaire; MUSE: Medication User Self-Evaluation; OR: Odds-Ratio; RMSEA: Root Mean Square Error of Approximation; ROC: Receiver Operating Curves; RR: Relative Risk. * It is not possible to show the results clearly, because of the way data is described in the paper.

158

The different items of the tools were organized into eight categories (Table 3). In total, 92.3%

159

(n=12) of the developed tools contained items related to drug therapy complexity, for example,

160

the number of different medications, the number of daily medication doses, and others. While

161

items associated with comorbidities were found in 76.9% (n=10) and adherence/subjective

162

aspects in 61.5% (n=8), and items correlated to sociodemographic information, adverse

163

events/adverse drug reactions and needs for assistance were included in 30.8% (n=4), 30.8%

164

(n=4) and 15.4% (n=2) of them, respectively.

165

Table 3: Characterization of items composing the tools (n=13). Type of items Author, year Awad et al., 201731

Complexity of drug therapy

Adherence/ subjective aspects

X

X

Covert et al., 201638

Comorbidities

Use of health services

Access to drugs

X

X

X

X

X

X

29

Crutzen et al., 2019

X

Doucette et al., 201327

X

X

X

Isaksen et al., 1999

X

X

X

Langford et al., 200636

X

28

Levy, 2003

35

Makowsky, Cave, Simpson, 201437

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Ploenzke et al., 201632

X

X

X

X

X

X

X

Snyder et al., 201534

X

X

33

X

Griend et al., 2015 Proportion

12/13

Needs for assistance

X

X X

X

X

X

4/13

2/13

X

Pammett et al., 2015

Rofu et al., 2018

Adverse events/ adverse drug reactions X

X

39

30

Sociodemographic information

X X

X 8/13

10/13

X

X 8/13

6/13

4/13

166

DISCUSSION

167 168

This review allowed us to map the tools developed for patient selection in outpatient

169

pharmaceutical services. This review confirms that there is a growing interest in the

170

development of patient selection tools in outpatient settings. Although the context

171

influences the type of service offered to patients, the main objective is to identify

172

patients who benefit from the pharmaceutical service and those at high risk to DRP. The

173

main type of tool application described in the studies was self-administration. Items

174

related to pharmacotherapy complexities were present in most of tools, followed by

175

those related to comorbidities. Many tools were developed empirically and without a

176

theoretical foundation to support the necessary steps for tool validation. Then,

177

validation procedures are necessary to confirm the reliability of the tools developed.

178

This emphasizes the importance of this review in showing the reader the tools that have

179

already been constructed, as well as the lack of developed and validated tools for the

180

patient selection for pharmaceutical services.

181

The review conducted by Alshakrak et al. (2019)21 also discusses the use of patient

182

identification tools for pharmaceutical services, but in a hospital setting. This fact may

183

be associated with the high hospital demand for clinical follow-up with the pharmacist,

184

reduced number of clinical pharmacists, cost reduction, and care reorientation1,10,11,41-42.

185

The studies found were mostly conducted in developed countries, such as the U.S. and

186

Canada, which may be associated with the structuring of the health system and services.

187

More structured pharmaceutical services, with a reorientation of the pharmacist’s role

188

and different ways of accessing these services, may have contributed to the

189

development of patient selection tools in these countries. In the U.S., clinical

190

pharmaceutical services are included in private health plans, namely, Medicare and

191

Medicaid. Thus, the high demand for pharmaceutical services, time constraints, and

192

high health spending may be the reasons that contributed to the development of the

193

tools in this context27,33,35,38,43,44.

194

Canada has a universal health care system, and the inclusion of pharmacists in the

195

health care team contributes to the optimization of care through collaborative work with

196

physicians and other health professionals. However, the number of pharmacists

197

providing clinical services is still limited, and there is a lack of defined criteria that

198

identify the patients who would benefit the most from pharmaceutical service36,37,45,46.

199

Therefore, patient selection and care management can contribute to reducing health care

200

costs and increasing the resolution and efficiency of pharmaceutical services1,10,11.

201

Most tools were for self-application27,36,29,35,34,37,38, and this can be related to the

202

countries where the tools were developed. However, it is important to consider the level

203

of schooling and health literacy for this approach to be effective, since the health

204

knowledge and the ability to interpret the items are important aspects to reach the true

205

test respondent score47.

206

While most developed tools have focused on identifying patients at risk of experiencing

207

DPR - the object of pharmaceutical care assessment and intervention - studies had

208

employed different methods to identify which factors/variables could predict this

209

outcome. Literature review and expert consultation were the most commonly used

210

techniques to identify criteria for composing the tool previously. However, the use of

211

other approaches, such as qualitative research, must be evaluated, since they can enrich

212

the instrument’s data. This alternative allows knowing the reality under the perspectives

213

of patients or health professionals and meets the real needs of the population48-49.

214

Studies used a database or specific population application and statistical analysis27,28-

215

30,33-35,38

216

small and convenient, curbing the external validity of the results presented, considering

217

that a vital validation procedure is an application on representative samples of the target

218

population and the performance of tests that ensure the external validation of the tool48.

219

Moreover, some studies were only descriptive36,31,32,37, and others consisted of

220

adaptations of other previously developed tools36,32,37.

221

Only the study conducted by Snyder et al. (2015)34 used psychometric procedures to

222

assess the reliability and validity of the developed tool. Developing instruments that aim

223

to measure psychological objects, such as health or pharmaceutical service’s needs,

224

researchers can be guided by protocols that help design Patient‐Reported Outcome

225

Measures (PROMs), such as Standards for Educational and Psychological Testing48 and

226

COnsensus-based Standards for the selection of health status Measurement INstruments

227

(COSMIN)50-51.

228

Most of the tools included items related to drug therapy and the presence of

229

comorbidities, such as the number of different medications, the use of high-risk

to confirm the predictive power of these variables. However, the samples were

230

medications, number of diseases, among others. In other studies, these factors are

231

associated with reasons that motivate clinical follow-up by the pharmacist19,52-53. It is

232

known that the presence of comorbidities influences drug therapy complexity. This may

233

adversely affect the effectiveness and safety of the treatment and, therefore, reduce

234

adherence, which was another aspect that was present in almost all tools. Although

235

adherence is an aspect that influences the effectiveness of treatment, it is essential to

236

consider the factors that lead to the patient’s non-adherence54. The use of health services

237

can influence the quality of the patient’s treatment, such as the number of

238

hospitalizations and medical visits. The hyper-utilization of care services is responsible

239

for a significant economic, human, and social impact on health services55,56.

240

The findings of this review show that the tools developed in the outpatient setting to

241

select a patient for pharmaceutical services are heterogeneous. The construct - intended

242

to measure, target population, and the pharmaceutical service for which they are

243

intended were not described in the studies. Also, the validation procedures are important

244

gaps in these studies. The rigor of the procedures employed in this construction step is

245

essential, as they may interfere with the validity of the tool score interpretations. We

246

also emphasize the importance of clearly establishing the construct that will be

247

investigated and measured, as well as the type of service in which it will be used. These

248

measures contribute to the following steps to be performed with quality and rigor to

249

ensure that the final version of the instrument has adequate reliability and validity48-49.

250

Strengths and limitations

251

A comprehensive search in the literature was performed, and language, pharmaceutical

252

service, or construct were not limiting factors. This review allowed understanding and

253

having a general idea of the tools developed. Moreover, the results showed that there are

254

few tools developed for patient selection for pharmaceutical services in ambulatory

255

settings, besides that the minority showed evidence of validity. The tools identified in

256

this review can be improved to provide evidence of adequate reliability and validity for

257

their active and widespread use in pharmaceutical services.

258

In addition, systematic reviews are required to evaluate the evidence of which tools are

259

most effective in selecting patients for the pharmacy service, focusing on a patient-

260

reported outcome. The use of COSMIN protocol contributes to assessment of the

261

validation procedures employed in the studies.

262

As limitations, the tools found have heterogeneous characteristics, which hinders their

263

comparison. Another limitation was the non-inclusion of instruments that were not

264

published in journals, but which are used in services, and those developed by

265

societies/health institutions.

266 267

CONCLUSION

268

Few studies that developed tools to select outpatients for pharmaceutical services were

269

found. The risk of DRP and the need for pharmaceutical services were the main

270

objective to identify patients. In addition, the developed tools demonstrated unclear

271

definition of the construct to be measured and unsatisfactory validation parameters.

272

Thus, it is necessary to improve the development of tools that can accurately identify

273

the patients who would benefit from the pharmaceutical service.

274 275

Funding: This study was partially funded by the Foundation for Research Support of

276

the State of Minas Gerais (Fapemig). The funding agency played no direct role neither

277

in the study design, the collection, analysis, and interpretation of data, the drafting of

278

the paper, nor in the decision to submit it for publication.

279

Declarations of interest: none.

280 281

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463

Electronic Databases

Strategy

Results

MEDLINE (Pubmed)

(((((((((((((((((((((Pharmaceutical Services[MeSH Terms]) OR Pharmaceutical Services[Text Word]) OR Services, Pharmaceutic[Text Word]) OR Services, Pharmacy[Text Word]) OR Pharmaceutic Services[Text Word]) OR Pharmaceutic Service[Text Word]) OR Service, Pharmaceutic[Text Word]) OR Services, Pharmaceutical[Text Word]) OR Pharmaceutical Service[Text Word]) OR Service, Pharmaceutical[Text Word]) OR Pharmacy Services[Text Word]) OR Pharmacy Service[Text Word]) OR Service, Pharmacy[Text Word]) OR Pharmaceutical Care[Text Word]) OR Care, Pharmaceutical[Text Word])) OR (((((((((((((((((((Community Pharmacy Services[MeSH Terms]) OR Community Pharmacy Services[Text Word]) OR Pharmaceutical Service, Community[Text Word]) OR Pharmaceutical Services, Community[Text Word]) OR Service, Community Pharmaceutical[Text Word]) OR Services, Community Pharmaceutical[Text Word]) OR Pharmacy Services, Community[Text Word]) OR Community Pharmacy Service[Text Word]) OR Pharmacy Service, Community[Text Word]) OR Services, Community Pharmaceutic[Text Word]) OR Services, Community Pharmacy[Text Word]) OR Community Pharmaceutic Services[Text Word]) OR Community Pharmaceutic Service[Text Word]) OR Pharmaceutic Service, Community[Text Word]) OR Pharmaceutic Services, Community[Text Word]) OR Service, Community Pharmaceutic[Text Word]) OR Community Pharmaceutical Services[Text Word]) OR Community Pharmaceutical Service[Text Word]) OR Service, Community Pharmacy[Text Word])) OR ((((((((Medication Therapy Management[MeSH Terms]) OR Medication Therapy Management[Text Word]) OR Management, Medication Therapy[Text Word]) OR Therapy Management, Medication[Text Word]) OR Drug Therapy Management[Text Word]) OR Management, Drug Therapy[Text Word]) OR Therapy Management, Drug[Text Word]) OR (MEDICARE Prescription Drug Improvement[Text Word] AND Modernization Act of 2003[Text Word]))) OR Clinical Pharmacy)) AND ((((((((Triage[MeSH Terms]) OR Triage[Text Word]) OR Triages[Text Word])) OR ((((((((((((((((((((((((((((((Patient Selection[MeSH Terms]) OR Patient Selection[Text Word]) OR Patient Selections[Text Word]) OR Selection, Patient[Text Word]) OR Selections, Patient[Text Word]) OR Research Subject Recruitment[Text Word]) OR Recruitment, Research Subject[Text Word]) OR Recruitments, Research Subject[Text Word]) OR Research Subject Recruitments[Text Word]) OR Subject Recruitment, Research[Text Word]) OR Subject Recruitments, Research[Text Word]) OR Research Subject Selection[Text Word]) OR Research Subject Selections[Text Word]) OR Selection, Research Subject[Text Word]) OR Selections, Research Subject[Text Word]) OR Subject Selection, Research[Text Word]) OR Subject Selections, Research[Text Word]) OR Selection for Treatment[Text Word]) OR Selection for Treatments[Text Word]) OR Treatment, Selection for[Text Word]) OR Treatments, Selection for[Text Word]) OR Selection of Subjects[Text Word]) OR Subjects Selection[Text Word]) OR Subjects Selections[Text Word]) OR Patient Recruitment[Text Word]) OR Patient Recruitments[Text Word]) OR Recruitment, Patient[Text Word]) OR Recruitments, Patient[Text Word]) OR Selection Criteria[Text Word]) OR Criteria, Selection[Text Word])) OR (((((((((((((((((((((((Risk Assessment[MeSH Terms]) OR Risk Assessment[Text Word]) OR Assessments, Risk[Text Word]) OR Risk Assessments[Text Word]) OR Health Risk Assessment[Text Word]) OR Assessment, Health Risk[Text Word]) OR Assessments, Health Risk[Text Word]) OR Health Risk Assessments[Text Word]) OR Risk Assessment, Health[Text Word]) OR Risk Assessments, Health[Text Word]) OR Assessment, Risk[Text Word]) OR (Risks[Text Word] AND Benefits[Text Word])) OR (Benefits[Text Word] AND Risks[Text Word])) OR Benefit-Risk Assessment[Text Word]) OR Assessment, Benefit-Risk[Text Word]) OR Assessments, Benefit-Risk[Text Word]) OR Benefit Risk Assessment[Text Word]) OR Benefit-Risk Assessments[Text Word]) OR Risk-Benefit Assessment[Text Word]) OR Assessment, Risk-Benefit[Text Word]) OR Assessments, Risk-Benefit[Text Word]) OR Risk Benefit Assessment[Text Word]) OR Risk-Benefit Assessments[Text Word])) OR ((((((((((Risk Adjustment[MeSH Terms]) OR Risk Adjustment[Text Word]) OR Adjustment, Risk[Text Word]) OR Adjustments, Risk[Text Word]) OR Risk Adjustments[Text Word]) OR CaseMix Adjustment[Text Word]) OR Adjustment, Case-Mix[Text Word]) OR Adjustments,

2338

Case-Mix[Text Word]) OR Case Mix Adjustment[Text Word]) OR Case-Mix Adjustments[Text Word])) OR ((((((((scor*) OR screen*) OR scale) OR classif*) OR assess*) OR instrument*) OR clinical assess* tool*) OR priorit*))) AND ((((((((((((((((((((((((((Ambulatory Care[MeSH Terms]) OR Ambulatory Care[Text Word]) OR Care, Ambulatory[Text Word]) OR Outpatient Care[Text Word]) OR Care, Outpatient[Text Word]) OR Health Services, Outpatient[Text Word]) OR Health Service, Outpatient[Text Word]) OR Outpatient Health Service[Text Word]) OR Service, Outpatient Health[Text Word]) OR Outpatient Health Services[Text Word]) OR Outpatient Services[Text Word]) OR Outpatient Service[Text Word]) OR Service, Outpatient[Text Word]) OR Services, Outpatient[Text Word]) OR Services, Outpatient Health[Text Word]) OR Urgent Care[Text Word]) OR Care, Urgent[Text Word]) OR Cares, Urgent[Text Word]) OR Urgent Cares[Text Word]) OR Clinic Visits[Text Word]) OR Clinic Visit[Text Word]) OR Visit, Clinic[Text Word]) OR Visits, Clinic[Text Word])) OR ((((((((Primary Health Care[MeSH Terms]) OR Primary Health Care[Text Word]) OR Care, Primary Health[Text Word]) OR Health Care, Primary[Text Word]) OR Primary Healthcare[Text Word]) OR Healthcare, Primary[Text Word]) OR Primary Care[Text Word]) OR Care, Primary[Text Word])) OR ((((((Outpatients[MeSH Terms]) OR Outpatients[Text Word]) OR Outpatient[Text Word]) OR Out-patients[Text Word]) OR Out patients[Text Word]) OR Out-patient[Text Word]))

EMBASE

#1 ('pharmacy (shop)'/exp OR 'apothecary' OR 'chemist (shop)' OR 'chemist shop' OR 'chemist`s shop' OR 'community pharmacy' OR 'community pharmacy services' OR 'pharmaceutical service' OR 'pharmaceutical services' OR 'pharmaceutical services, online' OR 'pharmacies' OR 'pharmacy' OR 'pharmacy (shop)' OR 'retail pharmacy' OR 'medication therapy management'/exp OR 'drug therapy management' OR 'medication management' OR 'medication reconciliation' OR 'medication therapy management')

1194

#2 ('patient selection'/exp OR 'patient selection' OR 'risk assessment'/exp OR 'assessment, safety' OR 'risk adjustment' OR 'risk analysis' OR 'risk assessment' OR 'risk evaluation' OR 'safety assessment') #3 ('ambulatory care'/exp OR 'ambulatory care' OR 'ambulatory care center' OR 'ambulatory service' OR 'dispensary care' OR 'extramural care' OR 'office visits' OR 'primary health care'/exp OR 'first line care' OR 'health care, primary' OR 'primary care nursing' OR 'primary health care' OR 'primary healthcare' OR 'primary nursing care' OR 'outpatient'/exp OR 'out patient' OR 'out-patient' OR 'out-patients' OR 'outpatient' OR 'outpatients' OR 'outward patient' OR 'patient, outward')

#4 #1 and #2 and #3

COCHRANE

#1

MeSH descriptor: [Pharmaceutical Services] explode all trees

CENTRAL

#2

(Pharmaceutical Services) (Word variations have been searched)

#3

(Pharmaceutical Care) (Word variations have been searched)

#4

(Care, Pharmaceutical) (Word variations have been searched)

#5

(Pharmacy Service) (Word variations have been searched)

#6

(Services, Pharmaceutical) (Word variations have been searched)

#7

(Services, Pharmacy) (Word variations have been searched)

#8

(Service, Pharmacy) (Word variations have been searched)

#9

(Pharmacy Services) (Word variations have been searched)

#10

(Pharmaceutical Service) (Word variations have been searched)

#11

(Service, Pharmaceutic) (Word variations have been searched)

#12

(Pharmaceutic Service) (Word variations have been searched)

#13

(Services, Pharmaceutic) (Word variations have been searched)

1941

#14

(Service, Pharmaceutical) (Word variations have been searched)

#15

(Pharmaceutic Services) (Word variations have been searched)

#16

MeSH descriptor: [Community Pharmacy Services] explode all trees

#17

(Community Pharmacy Services) (Word variations have been searched)

#18

(Service, Community Pharmaceutic) (Word variations have been searched)

#19

(Pharmaceutical Service, Community) (Word variations have been searched)

#20

(Service, Community Pharmaceutical) (Word variations have been searched)

#21

(Pharmaceutic Services, Community) (Word variations have been searched)

#22

(Pharmacy Service, Community) (Word variations have been searched)

#23

(Community Pharmaceutic Service) (Word variations have been searched)

#24

(Pharmaceutical Services, Community) (Word variations have been searched)

#25

(Services, Community Pharmacy) (Word variations have been searched)

#26

(Community Pharmacy Service) (Word variations have been searched)

#27

(Service, Community Pharmacy) (Word variations have been searched)

#28

(Community Pharmaceutical Service) (Word variations have been searched)

#29

(Services, Community Pharmaceutic) (Word variations have been searched)

#30

(Pharmaceutic Service, Community) (Word variations have been searched)

#31

(Community Pharmaceutic Services) (Word variations have been searched)

#32

(Pharmacy Services, Community) (Word variations have been searched)

#33

(Services, Community Pharmaceutical) (Word variations have been searched)

#34

(Community Pharmaceutical Services) (Word variations have been searched)

#35

MeSH descriptor: [Medication Therapy Management] explode all trees

#36

(Medication Therapy Management) (Word variations have been searched)

#37 (MEDICARE Prescription Drug Improvement and Modernization Act of 2003) (Word variations have been searched) #38

(Management, Medication Therapy) (Word variations have been searched)

#39

(Therapy Management, Medication) (Word variations have been searched)

#40

(Drug Therapy Management) (Word variations have been searched)

#41

(Management, Drug Therapy) (Word variations have been searched)

#42

(Therapy Management, Drug) (Word variations have been searched)

#43

(Clinical Pharmacy) (Word variations have been searched)

#44

{or #1-#43}

#45

MeSH descriptor: [Risk Adjustment] explode all trees

#46

(Risk Adjustment) (Word variations have been searched)

#47

(Case-Mix Adjustment) (Word variations have been searched)

#48

(Case-Mix Adjustments) (Word variations have been searched)

#49

(Adjustment, Case-Mix) (Word variations have been searched)

#50

(Case Mix Adjustment) (Word variations have been searched)

#51

(Adjustments, Case-Mix) (Word variations have been searched)

#52

(Adjustment, Risk) (Word variations have been searched)

#53

(Adjustments, Risk) (Word variations have been searched)

#54

(Risk Adjustments) (Word variations have been searched)

#55

MeSH descriptor: [Risk Assessment] explode all trees

#56

(Risk Assessment) (Word variations have been searched)

#57

(Benefits and Risks) (Word variations have been searched)

#58

(Risks and Benefits) (Word variations have been searched)

#59

(Benefit Risk Assessment) (Word variations have been searched)

#60

(Risk Benefit Assessment) (Word variations have been searched)

#61

(Assessments, Risk-Benefit) (Word variations have been searched)

#62

(Risk-Benefit Assessment) (Word variations have been searched)

#63

(Assessment, Risk-Benefit) (Word variations have been searched)

#64

(Benefit-Risk Assessments) (Word variations have been searched)

#65

(Assessments, Benefit-Risk) (Word variations have been searched)

#66

(Risk-Benefit Assessments) (Word variations have been searched)

#67

(Assessment, Benefit-Risk) (Word variations have been searched)

#68

(Benefit-Risk Assessment) (Word variations have been searched)

#69

(Assessment, Health Risk) (Word variations have been searched)

#70

(Risk Assessments) (Word variations have been searched)

#71

(Assessments, Health Risk) (Word variations have been searched)

#72

(Risk Assessments, Health) (Word variations have been searched)

#73

(Health Risk Assessments) (Word variations have been searched)

#74

(Risk Assessment, Health) (Word variations have been searched)

#75

(Assessments, Risk) (Word variations have been searched)

#76

(Assessment, Risk) (Word variations have been searched)

#77

(Health Risk Assessment) (Word variations have been searched)

#78

MeSH descriptor: [Triage] explode all trees

#79

(Triage) (Word variations have been searched)

#80

(Triages) (Word variations have been searched)

#81

MeSH descriptor: [Patient Selection] explode all trees

#82

(Patient Selection) (Word variations have been searched)

#83

(Subjects Selections) (Word variations have been searched)

#84

(Subjects Selection) (Word variations have been searched)

#85

(Selection of Subjects) (Word variations have been searched)

#86

(Recruitment, Patient) (Word variations have been searched)

#87

(Patient Recruitment) (Word variations have been searched)

#88

(Recruitments, Patient) (Word variations have been searched)

#89

(Patient Recruitments) (Word variations have been searched)

#90

(Criteria, Selection) (Word variations have been searched)

#91

(Selection Criteria) (Word variations have been searched)

#92

(Patient Selections) (Word variations have been searched)

#93

(Selection, Patient) (Word variations have been searched)

#94

(Selections, Patient) (Word variations have been searched)

#95

(Selection for Treatment) (Word variations have been searched)

#96

(Selection for Treatments) (Word variations have been searched)

#97

(Treatment, Selection for) (Word variations have been searched)

#98

(Treatments, Selection for) (Word variations have been searched)

#99

(Selection, Research Subject) (Word variations have been searched)

#100

(Research Subject Selection) (Word variations have been searched)

#101

(Subject Selections, Research) (Word variations have been searched)

#102

(Research Subject Selections) (Word variations have been searched)

#103

(Selections, Research Subject) (Word variations have been searched)

#104

(Subject Selection, Research) (Word variations have been searched)

#105

(Research Subject Recruitment) (Word variations have been searched)

#106

(Recruitment, Research Subject) (Word variations have been searched)

#107

(Subject Recruitment, Research) (Word variations have been searched)

#108

(Recruitments, Research Subject) (Word variations have been searched)

#109

(Research Subject Recruitments) (Word variations have been searched)

#110

(Subject Recruitments, Research) (Word variations have been searched)

#111

{or #45-#110}

#112

MeSH descriptor: [Ambulatory Care] explode all trees

#113

(Ambulatory Care) (Word variations have been searched)

#114

(Urgent Care) (Word variations have been searched)

#115

(Cares, Urgent) (Word variations have been searched)

#116

(Urgent Cares) (Word variations have been searched)

#117

(Care, Urgent) (Word variations have been searched)

#118

(Clinic Visits) (Word variations have been searched)

#119

(Visit, Clinic) (Word variations have been searched)

#120

(Clinic Visit) (Word variations have been searched)

#121

(Visits, Clinic) (Word variations have been searched)

#122

(Health Service, Outpatient) (Word variations have been searched)

#123

(Services, Outpatient) (Word variations have been searched)

#124

(Outpatient Services) (Word variations have been searched)

#125

(Outpatient Service) (Word variations have been searched)

#126

(Outpatient Health Services) (Word variations have been searched)

#127

(Outpatient Health Service) (Word variations have been searched)

#128

(Service, Outpatient) (Word variations have been searched)

#129

(Health Services, Outpatient) (Word variations have been searched)

#130

(Services, Outpatient Health) (Word variations have been searched)

#131

(Care, Ambulatory) (Word variations have been searched)

#132

(Care, Outpatient) (Word variations have been searched)

#133

(Outpatient Care) (Word variations have been searched)

LILACS

#134

MeSH descriptor: [Primary Health Care] explode all trees

#135

(Primary Health Care) (Word variations have been searched)

#136

(Primary Healthcare) (Word variations have been searched)

#137

(Care, Primary Health) (Word variations have been searched)

#138

(Healthcare, Primary) (Word variations have been searched)

#139

(Primary Care) (Word variations have been searched)

#140

(Care, Primary) (Word variations have been searched)

#141

(Health Care, Primary) (Word variations have been searched)

#142

MeSH descriptor: [Outpatients] explode all trees

#143

(Outpatients) (Word variations have been searched)

#144

(Outpatient) (Word variations have been searched)

#145

(Out-patient) (Word variations have been searched)

#146

(Out patients) (Word variations have been searched)

#147

(Out-patients) (Word variations have been searched)

#148

{or #112-#147}

#149

#44 and #111 and #148

((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( ( ( ( ( ( ( ( ( ( "PHARMACEUTICAL SERVICES" ) or "PHARMACEUTIC SERVICES" ) or "PHARMACEUTICAL CARE" ) or "PHARMACY SERVICES" ) or "SERVICES, PHARMACEUTIC" ) or "SERVICES, PHARMACEUTICAL" ) or "SERVICES, PHARMACY" ) or "CARE, PHARMACEUTICAL" ) or "PHARMACEUTIC SERVICE" ) or "PHARMACEUTICAL SERVICE" ) or "PHARMACY SERVICE" ) or "SERVICE, PHARMACEUTIC" ) or "SERVICE, PHARMACEUTICAL" ) or "SERVICE, PHARMACY" ) or "PHARMACEUTICAL CARE" ) or "SERVICIOS FARMACEUTICOS" ) or "ATENCION FARMACEUTICA" ) or "CUIDADOS FARMACEUTICOS" ) or "ASSISTENCIA FARMACEUTICA" ) or "ATENCAO FARMACEUTICA" ) or "CUIDADOS FARMACEUTICOS" ) or "SERVICOS DE ASSISTENCIA FARMACEUTICA" ) or "SERVICOS FARMACEUTICOS" ) or "COMMUNITY PHARMACY SERVICES" ) or "COMMUNITY PHARMACEUTIC SERVICES" ) or "COMMUNITY PHARMACEUTICAL SERVICES" ) or "PHARMACEUTIC SERVICES, COMMUNITY" ) or "PHARMACEUTICAL SERVICE, COMMUNITY" ) or "PHARMACEUTICAL SERVICES, COMMUNITY" ) or "PHARMACY SERVICES, COMMUNITY" ) or "SERVICE, COMMUNITY PHARMACEUTIC" ) or "SERVICE, COMMUNITY PHARMACEUTICAL" ) or "SERVICE, COMMUNITY PHARMACY" ) or "SERVICES, COMMUNITY PHARMACEUTIC" ) or "SERVICES, COMMUNITY PHARMACEUTICAL" ) or "SERVICES, COMMUNITY PHARMACY" ) or "COMMUNITY PHARMACEUTIC SERVICE" ) or "COMMUNITY PHARMACEUTICAL SERVICE" ) or "COMMUNITY PHARMACY SERVICE" ) or "PHARMACEUTIC SERVICE, COMMUNITY" ) or "PHARMACY SERVICE, COMMUNITY" ) or "SERVICIOS COMUNITARIOS DE FARMACIA" ) or "SERVICOS COMUNITARIOS DE FARMACIA" ) or "MEDICATION THERAPY MANAGEMENT" ) or "MEDICARE PRESCRIPTION DRUG IMPROVEMENT AND MODERNIZATION" ) or "MANAGEMENT, DRUG THERAPY" ) or "MANAGEMENT, MEDICATION THERAPY" ) or "THERAPY MANAGEMENT, DRUG" ) or "THERAPY MANAGEMENT, MEDICATION" ) or "DRUG THERAPY MANAGEMENT" ) or "ADMINISTRACION DEL TRATAMIENTO FARMACOLOGICO" ) or "ACTA DEL 2003 SOBRE MEJORAS DE MEDICAMENTOS RECETADOS Y" ) or "ADMINISTRACION DE LA TERAPIA FARMACOLOGICA" ) or "ADMINISTRACION DE TERAPIA DE MEDICACION" ) or "ADMINISTRACION DEL TRATAMIENTO MEDICAMENTOSO" ) or "GESTION DE LA MEDICACION" ) or "GESTION DE LA TERAPIA MEDICAMENTOSA" ) or "GESTION DEL TRATAMIENTO FARMACOLOGICO" ) or "GESTION DEL

28

TRATAMIENTO MEDICAMENTOSO" ) or "MANEJO DE LA MEDICACION" ) or "MANEJO DE LA QUIMIOTERAPIA" ) or "MANEJO DE LA TERAPIA MEDICAMENTOSA" ) or "CONDUTA DO TRATAMENTO MEDICAMENTOSO" ) or "ADMINISTRACAO DA TERAPIA FARMACOLOGICA" ) or "ADMINISTRACAO DE TERAPIA MEDICAMENTOSA" ) or "ADMINISTRACAO DO TRATAMENTO FARMACOLOGICO" ) or "ADMINISTRACAO DO TRATAMENTO MEDICAMENTOSO" ) or "CONDUTA QUIMIOTERAPICA" ) or "GESTAO DA MEDICACAO" ) or "GESTAO DA TERAPIA MEDICAMENTOSA" ) or "GESTAO DO TRATAMENTO FARMACOLOGICO" ) or "GESTAO DO TRATAMENTO MEDICAMENTOSO" ) or "CONDUTA NO TRATAMENTO MEDICAMENTOSO" [Palavras] and ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( "RISK ADJUSTMENT" ) or "ADJUSTMENT, CASE-MIX" ) or "ADJUSTMENT, RISK" ) or "ADJUSTMENTS, CASE-MIX" ) or "ADJUSTMENTS, RISK" ) or "CASE MIX ADJUSTMENT" ) or "CASE-MIX ADJUSTMENTS" ) or "RISK ADJUSTMENTS" ) or "CASE-MIX ADJUSTMENT" ) or "AJUSTE DE RIESGO" ) or "AJUSTE DE CASO" ) or "RISCO AJUSTADO" ) or "RISK ASSESSMENT" ) or "HEALTH RISK ASSESSMENT" ) or "RISKS AND BENEFITS" ) or "ASSESSMENT, BENEFIT-RISK" ) or "ASSESSMENT, HEALTH RISK" ) or "ASSESSMENT, RISK-BENEFIT" ) or "ASSESSMENTS, BENEFIT-RISK" ) or "ASSESSMENTS, HEALTH RISK" ) or "ASSESSMENTS, RISK" ) or "ASSESSMENTS, RISK-BENEFIT" ) or "BENEFIT RISK ASSESSMENT" ) or "BENEFIT-RISK ASSESSMENTS" ) or "BENEFITS AND RISKS" ) or "HEALTH RISK ASSESSMENTS" ) or "RISK ASSESSMENT, HEALTH" ) or "RISK ASSESSMENTS" ) or "RISK ASSESSMENTS, HEALTH" ) or "RISK BENEFIT ASSESSMENT" ) or "RISK-BENEFIT ASSESSMENTS" ) or "ASSESSMENT, RISK" ) or "BENEFIT-RISK ASSESSMENT" ) or "RISK-BENEFIT ASSESSMENT" ) or "MEDICION DE RIESGO" ) or "EVALUACION DE RIESGO" ) or "ANALISIS DE RIESGO" ) or "EVALUACION DE BENEFICIO-RIESGO" ) or "EVALUACION DE RIESGO-BENEFICIO" ) or "EVALUACION DE RIESGO PARA LA SALUD" ) or "MEDICAO DE RISCO" ) or "DETERMINACAO DO RISCO" ) or "AVALIACAO DE RISCO" ) or "ANALISE DE RISCO" ) or "AVALIACAO DO BENEFICIO-RISCO" ) or "AVALIACAO DO RISCOBENEFICIO" ) or "AVALIACAO DE RISCO PARA A SAUDE" ) or "TRIAGE" ) or "TRIAGES" ) or "TRIAJE" ) or "CLASIFICACION DE LA PRIORIDAD ASISTENCIAL" ) or "SELECCION ASISTENCIAL DE PACIENTES" ) or "CLASIFICACION DE PACIENTES" ) or "TRIADO ASISTENCIAL DE PACIENTES" ) or "TRIADO DE PACIENTES" ) or "TRIAGEM" ) or "TRIAGEM DE PACIENTES" ) or "TRIAGEM DE VITIMAS" ) or "TRIAGEM DE DEMANDA" ) or "PATIENT SELECTION" ) or "RESEARCH SUBJECT SELECTION" ) or "SELECTION FOR TREATMENT" ) or "SELECTION OF SUBJECTS" ) or "CRITERIA, SELECTION" ) or "PATIENT RECRUITMENTS" ) or "PATIENT SELECTIONS" ) or "RECRUITMENT, PATIENT" ) or "RECRUITMENT, RESEARCH SUBJECT" ) or "RECRUITMENTS, PATIENT" ) or "RECRUITMENTS, RESEARCH SUBJECT" ) or "RESEARCH SUBJECT RECRUITMENTS" ) or "RESEARCH SUBJECT SELECTIONS" ) or "SELECTION FOR TREATMENTS" ) or "SELECTION, PATIENT" ) or "SELECTION, RESEARCH SUBJECT" ) or "SELECTIONS, PATIENT" ) or "SELECTIONS, RESEARCH SUBJECT" ) or "SUBJECT RECRUITMENT, RESEARCH" ) or "SUBJECT RECRUITMENTS, RESEARCH" ) or "SUBJECT SELECTION, RESEARCH" ) or "SUBJECT SELECTIONS, RESEARCH" ) or "SUBJECTS SELECTION" ) or "SUBJECTS SELECTIONS" ) or "TREATMENT, SELECTION FOR" ) or "TREATMENTS, SELECTION FOR" ) or "PATIENT RECRUITMENT" ) or "SELECTION CRITERIA" ) or "RESEARCH SUBJECT RECRUITMENT" ) or "SELECCION DE PACIENTE" ) or "RECLUTAMIENTO DE PACIENTE" ) or "CRITERIOS DE SELECCION DE PACIENTES" ) or "RECLUTAMIENTO DE SUJETOS DE INVESTIGACION" ) or "SELECAO DE PACIENTES" ) or "RECRUTAMENTO DE PACIENTES" ) or "CRITERIOS DE SELECAO DE PACIENTES" ) or "RECRUTAMENTO DE INDIVIDUOS PARA A PESQUISA" ) or "RECRUTAMENTO DE SUJEITOS DA PESQUISA" ) or "RECRUTAMENTO DE PACIENTES PARA A PESQUISA" [Palavras]

Total

5505