Background
Methods
Data sources and search strategy
Eligibility criteria
Participants
Dimension | Definition |
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Organizational | Pharmacist is physically co-located with the GP or, the intervention is remote but encompassed within the same network |
Informational | Integration and access to clinical patient systems |
Clinical | Care delivery to patients and communication with GPs |
Functional | Capture of other actions taken by pharmacists integrated within GP settings such as medications education or administrative support |
Normative | Design of intervention in terms of shared goals and visions of activities involved and desired outcomes |
Financial | Financial implications from internally funded pharmacist interventions |
Intervention
Control
Study design
Outcomes
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PIP or high risk prescriptions as reported by included studies. Studies reported potentially inappropriate or high risk prescriptions using screening tools such as; Screening Tool of Older Person’s Prescriptions / Screening Tool to Alert doctors to Right Treatment (STOPP/START) and Beers criteria (explicit criteria), or the Medications Appropriateness Index (MAI), Prescribing Appropriateness Index and Drug Burden Index (DBI) (implicit criteria).
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The per-patient number of medications prescribed and change in the number of medications prescribed as reported by included studies. The definition varied across studies (e.g. some may use the number of repeat medications), however where possible we used the number of medications including acute and repeat prescribed medications.
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Health-related quality of life (HRQoL)
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Adverse events or harms
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Health service utilization
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Clinical physical outcomes
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Mental health outcomes
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Comparative resource use, costs and cost-effectiveness
Study selection and data extraction
Data synthesis
Risk of bias
Assessing quality of included studies
Results
Search results
Characteristics of included studies
Included studies, participants and outcomes reported
Author (year, Country) | Participants (Patients and healthcare professionals (HCPs)) | Intervention type, Control group, Domains of integration, Duration of intervention | Outcome measures | Results primary outcome |
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Randomised Controlled Trials | ||||
Britton [32] (1991, USA) | Total, n: 572 Age: NR Number of medications: Intervention: 8.72 \(\pm\) 3.54 Control: 8.52 \(\pm\) 3.47 HCPs: NR | Intervention type: Pharmacist reviewed patient treatment and cost. Medication profile review form attached to each patient file for review by GP. Post GP consult, the pharmacist reviewed files for no. meds, meds changes and compliance Control group: usual GP care Domains of integration: Organizational, informational, and clinical domains (moderate) Duration of intervention: 3 months | Primary Change in number of medications Change in cost due to no. of medications Secondary Discontinued medications no. and cost Medications added Dose change Cost | Number of medications at follow-up (mean standard deviation (SD)): Intervention: -0.21 (1.43) Control: + 0.48 (1.18) P < 0.001 |
Bryant [52] (2011, New Zealand) | Total, n: 493 Age (range): Intervention, 75.9 (64–92) Control, 74.9 (60–91) Number of medications: Intervention: NR Control: NR HCPs: 44 pharmacists | Intervention type: Patients had pharmaceutical care consultation with community pharmacist. Recommendations made to GP. The study pharmacist followed up with the patient clinically at 3, 6 and 12 months, updating of the pharmaceutical care plan as needed Control group: Wait-list control Domains of integration: Informational and clinical domains (moderate) Duration of intervention: 12 months | Primary MAI HRQoL, SF-36 Secondary No. of inappropriate medications Change in medications Recommendation implementation by GP | Mean MAI at 6-month follow-up: Intervention, 3.1 Control, 4.2 Mean difference at 6 months, 1.1 (95% CI -1.78 to -0.42, p = 0.003) SF-36: Emotional role: 13.4-unit difference, P = 0.024 Favouring control Social functioning: 7.7-unit difference, P = 0.019 Favouring control Change in social functioning not clinically significant change |
Campins [42] (2017, Spain) | Total, n: 503 Age, mean (SD): Intervention, 79.16 (5.5) Control, 78.78 (5.46) Number of medications: Intervention: 10.79 (2.52) Control: 10.91 (2.65) HCPs: NR | Intervention type: Pharmacist performed chart review. Pharmacist discussed recommendations with GP and therapeutic plan made. Recommendations were discussed with the patient, and a final decision was agreed by physicians and their patients in a face-to-face visit Control group: Usual GP care Domains of integration: Organizational, informational, and clinical domains (moderate) Duration of intervention: 12 months | Primary No. medications Secondary Medication appropriateness Intervention Effectiveness Change in medications Adherence (Morisky-Green) HRQoL, EQ5D Healthcare utilization Mortality | Mean number of medications at follow up: Intervention,10.03 Control, 10.91 P = 0.001 |
Geurts [43] (2016, The Netherlands) | Total, n: 512 Age (mean, SD): Intervention: 72.5 (7.735), Control: 73.1 (7.797) Number of medications: Intervention: 8.3 (2.721) Control: 7.9 (2.926) HCPs: 8 pharmacies/primary care sites | Intervention type: Community pharmacists had clinical medication review with patients. Recommendations made to GP. Implemented care intervention Control group: usual care Domains of integration: Organizational, informational, clinical, and normative domains (robust) Duration of intervention: 18 months | Primary Decrease in potential DRPs and PCIs Secondary Biomarkers for: Blood pressure, dyslipidaemia, BMI, diabetes and renal function | Total number of DRPs and PCIs at follow-up: Intervention, 208 Control not reported |
Graffen [53] (2004, Australia) | Total, n: 402 Age (median, range): 77.7 (66–102) Number of medications (mean): 8.4 HCPs: 8 general practices | Intervention type: Pharmacist reviewed medication profiles of rural patients in practice and made recommendations to GP. Changes were made by agreement between patient and GP Control group: usual care Domains of integration: Organizational, informational, and clinical domains (moderate) Duration of intervention: 18 months | Primary HRQoL SF-36 Secondary Recommendation uptake Hospitalizations | SF-36 Significant difference in vitality (p < 0.009) and mental health (p < 0.0001) in favour of intervention post-intervention |
Granas [39] (1998, UK) | Total, n: 285 Age (median, range): 65 (1—102): Number of medications (median, range): 5 (3–27) HCPs: 1 community pharmacist 2 GPs | Intervention type: Pharmacist performed chart-based medication review in practice. Recommendations made to GP. GP followed up with patient Control group: Usual care Domains of integration: Organizational, informational, and clinical domains (moderate) Duration of intervention: 24 months | Primary DRPs Secondary Recommendation uptake | DRPs at follow-up Intervention, 7.8% Control, 11.6% Statistically significant difference (p < 0.001) Adjusted ARR, 26% |
Hanlon [34] (1996, USA) | Total, n: 208 Age (mean, SD): Intervention, 69.7 (3.5) Control, 69.9 (4.1) Number of medications (mean (SD)): Intervention: 7.6 (2.8) Control: 8.2 (2.7) HCPs: 2 pharmacists | Intervention type: Comprehensive medication review with the pharmacist in practice and follow-up at 11.5–13 months Control group: usual care with closeout interview by second pharmacist blinded to allocation Domains of integration: Organizational, informational, clinical, and financial domains (robust) Duration of intervention: 13 months | Primary Prescribing appropriateness; MAI Secondary Improvement in inappropriate prescribing Medication compliance Medication knowledge Number of medications HrQoL, SF-36 | Adjusted MAI at 12 months (mean, SD) Intervention, 12.8 (0.7) Control, 16.7 (0.7) Inappropriate prescribing scores declined more in intervention than control at 12 months: 28% vs 5% (p = 0.0002) |
Jameson [35] (2001, USA) | Total, n: 168 Age: Intervention: 51.4 (10.1) Control: 52.5 (10.6) Number of medications: NR HCPs: 1 pharmacist 133 physicians (in 4 practices) | Intervention type: Medication review with patient in practice. Discussed DRPs with GP. Care plan developed with GP. Changes discussed with patient Control group: Usual care Domains of integration: Organizational, informational, and clinical domains (moderate) Duration of intervention: 9 months | Primary Medical/drug costs Secondary Adverse effects | Medication cost at follow-up $ Intervention: 1657 (1068) Control: 1602 (1202) No significant change |
Krska [40] (2001, UK) | Total, n: 381 Age (mean, range): Intervention: 74.8 (65–90), Control: 75.2 (65–93) Number of medications (mean, SD): Intervention: 7.4 ± 2.7 Control: 7.7 ± 2.8 HCPs: NR | Intervention type: Pharmacist performed chart review followed by medication review with patient in their own home. Pharmaceutical care plan developed in practice. Notes forwarded to GP who indicated level of agreement. Implemented actions where appropriate Control group: Usual care Domains of integration: Organizational, informational, and clinical domains (moderate) Duration of intervention: 3 months | Primary Pharmaceutical care issues Secondary Medication costs HRQoL, SF-36 Healthcare utilization | PCIs at 3 months Intervention: 256 (21.2%) Control: 856 (60.7%) Crude ARR: 39.5% |
Kwint [44] (2011, The Netherlands) | Total, n: 118 Age (mean ± SD): Intervention: 78.7 (6.8) Control: 80.0 (7.2) Number of medications (mean ± SD): Intervention: 10.3 (3.1) Control: 9.8 (3.6) HCPs: 6 community pharmacists; each community pharmacist recruited two GPs | Intervention type: Community pharmacist collated information from pharmacy and GP. Data reviewed by 2 pharmacists. Results sent to community pharmacist to discuss with GP Control group: Wait-list control Domains of integration: Informational and clinical domains (moderate) Duration of intervention: 6 months | Primary DRPs Secondary Medication changes Recommendation’s uptake | DRPs at baseline Intervention: 4.5 Control: 4.4 DRPs at 6 months Intervention: 3.2 Control: 4.2 |
Lenaghan [41] (2007, UK) | Total, n: 136 Age: 84.3 Number of medications: 9.45 HCPs: 1 community pharmacist 9 GPs based in one practice | Intervention type: Comprehensive medication review in patient’s home. Community pharmacist had notes from both pharmacy and medical notes. Recommendations discussed and implemented with GP and discussed with patients. Further follow-up at 6–8 weeks Control group: Wait-list control Domains of integration: Organizational, informational, and clinical domains (moderate) Duration of intervention: 6 months | Primary Unplanned hospital admissions Secondary Mortality HRQoL, EQ5D No. of medications | Hospitalizations at follow-up: Intervention, 21 Control, 20 P = 0.8 |
Sellors [36] (2003, Canada) | Total, n: 889 Age (mean, SD): Intervention: 74.0 (6.1) Control group: 74.0 (6.0) Number of medications (mean): Intervention: 12.4 Control: 12.2 HCPs: n = 24 pharmacists n = 48 physicians | Intervention type: Community pharmacists (who had additional post-university training in the prevention, identification, and resolution of drug-related problems) conducted face-to-face medication reviews with the patients and then gave written recommendations to the physicians to resolve any drug-related problems Control group: Usual care Domains of integration: Organizational, informational, clinical, and financial domains (robust) Duration of intervention: 5 months | Primary DRPs Secondary Uptake of recommendations Length of physician meeting Reasons for not implementing recommendations Cost HRQoL, SF-36 | Recommendations uptake at follow-up: Fully implemented: 46.3% (506/1093) Partially implemented: 9.3% (102/1093) Unsuccessful implementation: 16.7% (182/1093) |
Taylor [37] (2003, USA) | Total, n: 69 Age (mean, SD): Intervention: 64.4 (13.7) Control: 66.7 (12.3) Number of medications (mean, SD): Intervention: 6.3 (2.2) Control: 5.7 (1.7) HCPs: 4 pharmacists | Intervention type: Patients in the intervention group received usual care plus pharmacotherapeutic interventions by a pharmacist during regularly scheduled office visits before seeing a physician. Pharmacist developed education packs for patients with diabetes, hypertension, dyslipidaemia and anti-coagulation services Control group: Medical records review at baseline and 12 months later performed by pharmacist, no advice, or recommendations to patient/physician Domains of integration: Organizational, informational, clinical, and financial domains (robust) Duration of intervention: 12 months | Primary Prescribing appropriateness (MAI) and ADRs Secondary Hospitalizations and ED visits Hypertension outcomes Biomarkers for: Diabetes, dyslipidaemia, blood pressure and anticoagulation services HRQoL, SF-36 | Inappropriate prescriptions at baseline (MAI) Intervention: 210 Control: 207 Inappropriate prescriptions at follow-up Intervention: 155 Control: 224 Ratings for inappropriate prescribing improved in all 10 domains evaluated in the intervention group but worsened in 5 domains in the control group |
VanDerMeer [45] (2018, The Netherlands) | Total, n: 157 Age (mean, SD): Intervention: 75.7 (6.9) Control: 76.6 (6.7) Number of medications (mean, SD): Intervention: 8.4 (2.4) Control: 9.3 (3.2) HCPs: 15 community pharmacies | Intervention type: Pharmacotherapeutic review with community pharmacist. Written recommendations forwarded to GP followed by an MDT meeting where an action plan was decided. This was discussed with the patient and decisions taken were followed up Control group: Wait-list control Domains of integration: Organizational, informational, and clinical domains (moderate) Duration of intervention: 3 months | Primary Change in DBI Secondary Presence of anticholinergic/sedative side effects Falls Cognitive function Activities of daily living HRQoL, EQ5D-3L Hospital admission Mortality | Proportion of patients with a decrease of DBI ≥ 0.5 at follow up Intervention: 17.3% Control: 15.9% OR 1.04, CI 0.47 to 2.64, p = 0.927) |
Verdoorn [46] (2019, The Netherlands) | Total, n: 629 Age (range): Intervention: 80 (76–83) Control: 78 (74–82) Number of medications (median, IQR): 9.0 (7.5–10.5) HCPs: 43 pharmacists 113 GPs | Intervention type: Patients received a clinical medical review from community pharmacist who had both pharmacy data and medical history. Potential DRPs reported and discussed face-to-face with GP. PCP proposed and actions agreed. Two follow-up appointments to review changes made Control group: Wait-list control Domains of integration: Organizational, informational, and clinical domains (moderate) Duration of intervention: 6 months | Primary EQ5D-5L EQ5D-VAS No. of health problems Secondary Number of medications Medications commenced or discontinued | EQ5D-5L at follow up: Intervention, 0.73 (0.20) Control, 0.74 (0.18) EQ5D-VAS at follow up: Intervention, 70 (16) Control, 69 (15) HR-QoL measured with EQ-VAS increased by 3.4 points (95% confidence interval [CI] 0.94 to 5.8; p = 0.006), Number of health problems with impact on daily life: Decreased by 12% in intervention (difference at 6 months − 0.34; 95% CI − 0.62 to − 0.044; p = 0.024) as compared with the control group |
Vinks [47] (2009, The Netherlands) | Total, n: 174 Age (mean, SD): Intervention: 76.6 (6.5) Control: 76.6 (6.4) Number of medications (mean, SD): Intervention: 8.8 (2.5) Control: 8.5 (2.3) HCPs: 16 pharmacies | Intervention type: Community pharmacists reviewed patients’ medications and compiled a list of recommended changes in medication was compiled by the pharmacist for the patients in the intervention group. Recommendations for medication change were discussed with the general practitioner (GP). Repeat screening conducted at follow-up Control group: Usual care Domains of integration: Informational and clinical domains (moderate) Duration of intervention: 12 months | Primary DRPs Secondary No. of medications Recommendations and uptake | Mean DRPs at follow up Intervention: 3.29 Control: 3.62 Mean difference –16.3%; 95% CI –24.3, –8.3) |
Zillich [38] (2014, USA) | Total, n: 961 Age (mean, SD): 73 (13) Number of medications: Intervention: 14 (11) Control: 13 (8) HCPs: NR | Intervention type: Nurse completed admission procedures and forwarded meds info to MTM intervention provider. Pharmacy technician called to verify all meds. Community pharmacist then rang and completed comprehensive med review with patient/carer. Developed medication related action plan. Pharmacist provided follow-up phone call on day 7, and again at day 30 and 60 as needed Control group: Usual home health care Domains of integration: Organizational, informational, and clinical domains (moderate) Duration of intervention: 60 days | Primary 60-day hospitalizations Secondary MRPs Recommendation uptake | Hospitalizations at follow up: Intervention: 83 Control: 112 Adjusted OR: 1.26, 95 percent CI: 0.89–1.77, p = 0.19) |
Cluster Randomised Controlled Trials | ||||
Bernsten (2001) [48] Multiple sites: (seven EU countries) | Total, n: 2454 Age (median, IQR): 74 (8) Number of medications: Intervention: 7.05 (2.51) Control: 6.97 (2.51) HCPs: 190 community pharmacies | Intervention type: Pharmacists completed study training and informed local GPs and formed formal links. Patient received pharmaceutical care intervention in collaboration with GPs Control group: Usual care Domains of integration: Clinical domain (minimum) Duration of intervention: 18 months | Primary HRQoL; SF-36 Secondary: Hospitalizations Cost Compliance Recommendation acceptance | HRQoL: A general decline in health-related quality of life over time was observed in the pooled data; however, improvements were achieved in patients involved in the pharmaceutical care programme in some countries |
Sorensen [54] (2004, Australia) | Total, n: 400 Age (mean, range): Intervention 72.3 (37–100), control 71.4 (25–99) Number of medications: Intervention: 9.7 (9.1–10.3) Control: 8.9 (8.3–9.4) HCPs: n = 53 pharmacists n = 92 GPs | Intervention type: GPs were the units of randomization. GPs made referrals to the community pharmacist who conducted medication review based on pharmacy data and medical records. Prepared report for GP, recommendations discussed at MDT meeting and action plan developed. GP implemented plan with patient agreement Control group: Usual care Domains of integration: Organizational and clinical domains (moderate) Duration of intervention: 6 months | Primary DUSOI-A Secondary Problems and recommendations HRQoL, SF-36 ADEs Costs | Change in DUSOI-A at follow up: Intervention, reduced by 4.92 Control, reduced by 1.34 |
Varas-Doval [49] (2020, Spain) | Total, n: 1403 Age (mean, SD): Intervention: 75.34 (6.46) Control: 74.92 (6.59) Number of medications (mean, SD): Intervention: 7.74 (2.5) Control: 7.39 (2.37) HCPs: n = 178 pharmacies, n = 250 pharmacists | Intervention type: Community pharmacists provided Medication review with follow up (MRF). Pharmacist communicated with GPs via face to face or telephone. Follow up on a monthly basis for duration of the intervention Control group: Usual care Domains of integration: Organizational and clinical domains (moderate) Duration of intervention: 8 months | Primary Uncontrolled health problems Secondary DRPs Interventions made by pharmacists | Uncontrolled health problems at follow up [mean (95% CI)]: Intervention: 0.65 (0.43, 0.88) Control: 0.69 (0.47, 0.91) Reduction in the number of uncontrolled health problems: Intervention: -0.72 (95% CI: -0.80, -0.65) Control: -0.03 (95%CI: -0.10, 0.04) |
Non-Randomised Controlled Trials | ||||
Leendertse [50] (2013, The Netherlands) | Total, n: 674 Age (95% CI): Intervention: 75.8* (74.9–76.4) Control: 75.7* (75.1–76.7) Number of medications: Intervention: 7.8* (7.7- 8.2) Control: 7.9* (7.5 – 8.2) HCPs: 42 primary health care settings. 1 intervention and 1 control GP. Number of GPs and pharmacists not reported * Values are results of the linear mixed-effects model | Intervention type: In each practice, patients were recruited from community pharmacy, Community pharmacist conducted structured pharmacotherapeutic review with patient based on pharmacy history and medical notes. Pharmacist and GP met to discuss PCP. Agreed changes implemented and monitored by GP/practice nurse Control group: Usual care Domains of integration: Organizational, informational, and clinical domains (moderate) Duration of intervention: 12 months | Primary Medication-related hospitalizations Secondary Survival HRQoL, EQ5D ADEs Drug therapy problems and care issues Interventions recommended | Hospitalizations at follow-up: Intervention: 6 Control: 10 Reduction in hospitalizations in intervention 1.6% vs 3.2% (HR 0.50, 95%CI 0.12–1.59) |
Controlled Before-After | ||||
Sloeserwij [51] (2019, The Netherlands) | Total, n: 11,928 Age (mean, SD): 75 (8) Number of medications: 6 (5–8) HCPs: 9 pharmacists 25 general practices | Intervention type: Pharmacists embedded in general practices for three months prior to intervention. Pharmaceutical care for high-risk patients- pharmacist performed medication reviews with patients and medications reconciliation amongst other practice-related activities Control group: Usual care was normal GP review. Usual care plus was medication review conducted by accredited community pharmacist Domains of integration: Organizational, informational, and clinical domains (moderate) Duration of intervention: 12 months | Primary Medication-related hospitalizations Secondary DBI Costs | Medication-related hospitalizations at follow up: Intervention: 230 Usual care: 355 Usual care plus: 237 Rate ratio of medication‐related hospitalizations in the intervention group compared to usual care was 0.68 (95% CI: 0.57–0.82) and 1.05 (95% CI: 0.73–1.52) compared to usual care plus |
Interventions and comparators
Characteristics of included health-economic studies
Author (year, study) | Country perspective | Analysis type | Follow-up/time horizon | Control | Intervention | Results |
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Campins (2019, Campins study) | Third party payer, public, Spain | CBA | 12 months post-intervention | Usual GP care | Pharmacist performed chart review. Pharmacist discussed recommendations with GP and therapeutic plan made. Recommendations were discussed with the patient, and a final decision was agreed by physicians and their patients in a face-to-face visit | Drug expenditure savings per patient/year attributable to intervention: €88.42 Drug costs reduction: Intervention: €321.43 (CI = 233.77–409.79) Control: €232.94 (CI = 141.64–323.15) Intervention cost: €37.17 The estimated return per Euro invested in the programme: €3.27 per patient a year on average |
Cowper (1998, Hanlon study) | Third party payer, public, US | CEA | 12 months | Usual care with closeout interview by second pharmacist blinded to allocation | Comprehensive medication review with the pharmacist in practice and follow-up at 11.5–13 months | Cost-effectiveness as reported by MAI score: €1122.64/one unit change (estimated by researchers) |
Jodar-Sanchez (2015, Varas-Doval study) | Third party payer, public, Spain | CUA | 12 months | Usual care | Community pharmacists provided Medication review with follow up (MRF). Pharmacist communicated with GPs via face to face or telephone. Follow up on a monthly basis for duration of the intervention | Incremental effectiveness (intervention vs control) 0.0156 QALYs (SD = 0.004) (95% CI 0.008– 0.023) Mean incremental total cost of intervention -€321.88 ± 190.95 (95% CI -696.14 to 52.37) |
Noain (2017, Varas-Doval study) | Third party payer, public, Spain | Micro-costing, cost analysis | 12 months | Usual care | Community pharmacists provided medication review to patients with follow-up with GPs and patients. Same study as Jodar-Sanchez above | Service provider cost per patient ranged from €251.72 (SD 90.5) to €398.12 (SD 164.4) The mean initial investment per pharmacy was €5899.92 and the mean annual maintenance costs €3940.13 The potential service price ranged from €304.37 to €806.52 per patient a year |
Malone (2000, Carter study) | Third party payer, public, US | Cost analysis | Not reported, costs calculated for 12 months prior to trial and 12 months of trial | Usual GP care | Patients were assessed by pharmacists at least three times (baseline, 6 & 12 months) but could see the patients as often as was medically indicated. Documentation via a standardised form was used for all patient encounters. Pharmacists saw patients in clinic or spoke on the phone. Discussed recommendations with GP | Mean increases in total health care costs were €1553.89 for the intervention group and €2000.25 for the control group (p = 0.06) |
Effectiveness studies with cost and cost-effectiveness data | ||||||
Bernsten (2001) | Third party payer, pan-European study, reported from Sweden | Cost analysis | 18-month trial period | Usual care | Pharmacists completed study training and informed local GPs and formed formal links. Patient received pharmaceutical care intervention in collaboration with GPs | Total cost: Between-group analysis indicated that there were no significant differences between the total cost for control and intervention patients in any country (Mann–Whitney, p > 0.05) Hospitalisations Germany, intervention patients had significantly lower costs associated with hospitalisations and contacts with specialists compared with control patients in the second 6-month period (Mann–Whitney test, p < 0.05) Cost savings Cost savings were achieved in most of the countries at each assessment period |
Britton (1991) | Third party payer, US | Cost analysis | 3-month trial period | Usual care | Pharmacist reviewed patient treatment and cost. Medication profile review form attached to each patient file for review by GP. Post GP consult, the pharmacist reviewed files for no. meds, meds changes and compliance | Intervention total cost savings: €287.93 Control total cost savings: costs increased by €1295.93 Intervention total cost avoidance: €1588.39 |
Jameson (2001) | Third party payer, US | Cost analysis | 9-month trial period | Usual care | Medication review with patient in practice. Discussed DRPs with GP. Care plan developed with GP. Changes discussed with patient | No significant differences were demonstrated in the changes in medical or drug costs between the consult and the control groups Drug Changes at follow-up Intervention: Change €73.87 (904.06) Control: Change €23.45 (11,257.98) Medical changes at follow-up Intervention: Change €632.02 (11,716.46) Control: Change €367.02 (12,231.22) |
Krska (2001) | Third party payer, UK | Cost analysis | 3-month trial period | Usual care | Pharmacist performed chart review followed by medication review with patient in their own home. Pharmaceutical care plan developed in practice. Notes forwarded to GP who indicated level of agreement. Implemented actions where appropriate | No significant difference at baseline or follow-up Intervention Medication Costs (mean, SD) Baseline: €76.27 (56.52) Follow-up: €75.49 (57.55) Control Medication Costs Baseline: €83.21 (65.13) Follow-up: €82.84 (61.90) |
Sellors (2003) | Third party payer, Canada | Cost analysis | 5-month trial period | Usual care | Community pharmacists (who had additional post-university training in the prevention, identification, and resolution of drug-related problems) conducted face-to-face medication reviews with the patients and then gave written recommendations to the physicians to resolve any drug-related problems | Mean daily cost of medications per patient (intervention vs control) €4.10 vs €3.94 (p = 0.72) Mean total cost of medications per patient (intervention vs control) €2.92 vs €3.08 (p = 0.78) Mean cost of healthcare resources per patient (intervention vs control) €1047.97 vs €1062.78 (p = 0.45) |
Sloeserwij (2019) | Third party payer, Netherlands | Cost analysis | 12-month trial period | Usual care was normal GP review. Usual care plus was medication review conducted by accredited community pharmacist | Pharmacists embedded in general practices for three months prior to intervention. Pharmaceutical care for high-risk patients- pharmacist performed medication reviews with patients and medications reconciliation amongst other practice-related activities | Intervention vs usual care only. No difference in healthcare or medication costs reported Ratio of healthcare costs in intervention group vs usual care group (95% CI) Primary care costs: 1.08 (0.99–1.17) p = 0.073 Secondary care costs: 0.92 (0.65–1.29) p = 0.622 Medication costs: 1.04 (0.98–1.10) p = 0.172 Secondary healthcare costs related to hospitalisations: No differences: adjusted ratio 0.82 (95% CI 0.64–1.06) |
Sorensen (2004) | Third party payer, Australia | CEA | 6-month trial period | Usual care | GPs were the units of randomization. GPs made referrals to the community pharmacist who conducted medication review based on pharmacy data and medical records. Prepared report for GP, recommendations discussed at MDT meeting and action plan developed. GP implemented plan with patient agreement | The cost–effectiveness ratio for the intervention based on cost savings, reduced adverse events and improved health outcomes was small Cumulative cost/patient over the 8 months from enrolment Intervention: €5806.45 Control: €6160.15 Net cost saving per intervention patient (marginal cost benefit) was €58.05 per patient relative to controls Incremental cost–effectiveness ratio in reducing ADEs and in improving DUSOI-A for the groups ADEs: €74.18 DUSOI-A: €69.88 |
Domains of integration in included effectiveness studies
Risk-of-Bias Summary
Certainty of the evidence
The effectiveness and cost of integrating pharmacists within general practice to optimize prescribing and health outcomes in primary care patients with polypharmacy | |||
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Patients or population: Patients over the age of 65 on five or more medications Settings: Primary care Intervention: Pharmacist integration to optimise medications and improve patient outcomes Comparison: Usual care | |||
Outcomes | Impact | Number of participants (Studies) | Certainty of the evidence (GRADE) |
Potentially inappropriate prescribing | Ten studies favoured pharmacist integration, eight of which demonstrated signficant changes in favour of the pharmacist integration group | 1486 participants (10 studies) | ⊕⊕⊕Ɵa Moderate |
Number of medications | Mean difference -0.80 [-1.17, -0.43]. Direction of effect of four of the seven studies favoured pharmacist integration in reducing the number of medications prescribed. Confidence intervals for three studies included zero | 1176 participants (7 studies) | ⊕⊕⊕Ɵa Moderate |
Health-related quality of life | Unclear effect, the direction of results could not be determined due to the heterogeneity in reported results | 4535 participants (15 studies) | ⊕ƟƟƟa, b, c Very low |
Adverse drug events | Unclear effect, pharmacist integration tended to reduce the risk of ADEs, two studies reported significant results and two studies did not | 409 participants (4 studies) | ⊕⊕ƟƟa, c Low |
Mortality | No clear effect on mortality | 327 participants (2 studies) | ⊕⊕ƟƟd Low |