Evaluation of pharmaceutical care services in the Middle East Countries: a review of studies of 2013–2020

Despite the fact that pharmaceutical care (PC) has evolved into a whole philosophy and a standard for providing health care as a result of pharmacy organizations’ continuing professional development programs around the world [1], the importance of pharmaceutical care services and the implementation of pharmacy practice research has not been clearly defined in the Middle East countries so that independent observers can detect its presence, strength, and sustainability [2].

In general, because of disparities in training programs, healthcare systems, and regulatory frameworks, the state of pharmacy practice in the Middle Eastern differs among various nations. However, because of the near vicinity of the two locations, the same language, culture, and history, there are many parallels in terms of practicing facilitators and barriers [3].

A more modern definition of Pharmaceutical Care Network Europe (PCNE), which specifies pharmaceutical care as a service provided by pharmacists, states: Pharmaceutical Care is that the pharmacist’s contribution to the care of people is to optimize the use of medicines and improve health outcomes [4].

The pharmacist’s roles in patient care have expanded from the traditional tasks of dispensing medications and providing basic medication counseling to working with other health care professionals and the general community. This has resulted greater in the pharmacist’s participation in different health care systems involving in/out-patients pharmacies, general medical practices, and hospitals [5]. Six papers from Jordan, the United Arab Emirates, Sudan, and Iraq were found in a systematic review looking at pharmacists’ intervention programs for diabetic patients in these Arab nations. These trials revealed considerable gains in patients’ knowledge, adherence, and therapeutic results [6].

On the other hand, another systematic review looked at how people felt about the role and offerings of community pharmacists in Arabic-speaking Middle Eastern nations, showing the widespread belief that these professionals offer services that are business-oriented. It was also observed that the public’s impression of the pharmacist’s involvement in clinically oriented services was poor [3].

The pharmacy profession has been thriving in the Middle East. In Jordan, we found that the number of community pharmacies has surpassed 2200, and the active workforce is anticipated to include 12,000 registered pharmacists. In Jordan, pharmaceutical care services are highly developed in recent years, resulting in improved patient outcomes and therapy management in different medical conditions and healthcare settings [7‐10].

Another systematic review analyzed suggestions for program creation and looked at how antimicrobial stewardship methods affected prescribing practices and antibiotic appropriateness in the Middle East. Giving clinical pharmacists a more prominent role in the administration and prescription of antibiotics was one of the recommendations made by Jordan, the United Arab Emirates, Qatar, Saudi Arabia, and Lebanon [11].

Although the benefits of pharmaceutical care interventions by pharmacists within various healthcare settings have been documented in the literature, particularly in systematic reviews, [12‐17] there is a need to evaluate the impact holistically through a multidimensional assessment of clinical, economic, and humanistic outcomes [18].

Identifying these issues can help in determining what factors impede or facilitate intervention, the development of solutions to overcome process obstacles, the introduction of innovations into health systems, or the promotion of their widespread usage and sustainability [19]. Implementation research may be a crucial method for ensuring the successful adoption and sustainability of Clinical Pharmacy Services (CPS) in countries where they have not yet been established [20‐22].

However, Pew Health Profession Commission (PHPC) recommended that pharmaceutical education “should begin with a curricular reform to be qualified to perform pharmaceutical care” [23]. By looking at the educational side of the Middle East region, some studies showed that some of the universities who nationally certified for pharmacy schools have international accreditation from recognized pharmacy authorities [24].

According to a study of the current state of PCs services in a number of Arabic-speaking Middle East (ME) countries, the pharmaceutical care concept has only recently been introduced to many (ME) countries, and is still frequently confused with clinical pharmacy, which remains a priority in several countries of the region. In many Middle Eastern nations, pharmacy education is undergoing rapid transition and some pharmacy institutions have launched or plan to introduce the Pharm.D degree to replace the traditional Bachelor of Pharmaceutical Science degree. These improvements are expected to reflect a greater understanding and implementation of pharmaceutical care in various forms, such as medication management services, in hospital and community settings [25].

These services will not only help in determining and approving the critical tasks of pharmacists or clinical pharmacists aid or improving the implementation of Pharmaceutical Care services, but will also increase collaboration between pharmacists and other health care providers. Therefore, the purpose of this search investigation was to answer the following research question:

The current research is the first to examine the impact of PCs on Middle Eastern low- and middle-income countries.

Only 129 articles were included in this scoping review. However, all included studies have been published from 2013 to 2020. The massive majority of studies were from Jordan, with the largest number of published studies (25.6%, n = 33), followed by Saudi Arabia (16.3%, n = 21), Turkey (11.6%, n = 15), Iran (10.9%, n = 14) then Egypt (9.3%, n = 12), Qatar (6.2%, n = 8), Cyprus (5.4%, n = 7), Iraq (4.7%, n = 6) and Kuwait (3.1%, n = 4) While Lebanon and Palestine (2.3%, n = 3), next Israel and Oman (1.6%, n = 2 and 0.8%, n = 1, respectively). Based on the World Bank Classification of countries by income level 2019–2020 (World Bank Data 2020), we found thirteen Middle East Countries. Six of them were identified as Middle-Income countries including Jordan, Iran, Egypt, Iraq, and Turkey, six countries considered as High income representing in Qatar, Cyprus, Saudi Arabia, Israel, and Oman, and one country Palestine was considered a Low-income country.

Most of the studies included in this review reported the effective role of pharmacist/ clinical pharmacists in improving HRQoL/ QoL. This finding is also compatible with results from previous studies, which showed significant value and the positive impact of pharmacists on the QoL among older adult patients in rural areas[75]. Moreover, a study conducted in 2014 recited a statistical improvement in the HRQoL after pharmaceutical care intervention[76]. A review supports this systematic review was carried on women with breast cancer (BC) in the Middle East countries [77]. A cross-sectional study conducted by Jordanian pharmacists to determine the predictors, levels, and prevalence of anxiety and stress, as well as the relationship between these factors and quality of life in recently displaced Iraqis, discovered that pharmacists play an important role in reducing anxiety and stress among refugees. Reducing and managing anxiety and stress may help refugees around the world improve their quality of life [78]. While we found that some studies have traded different services that can be provided by pharmacists or clinical pharmacists. Majdoleen AL Alawneh, showed that the medication review service provided by professional pharmacists can enhance DRPs and anxiety ratings, according to this study [79].

Similar results were found in different studies. Pharmacists are capable of assisting patients in improving their health by lowering drug-related side effects and increasing medication adherence, as well as reducing physician visits, and hospital admissions, and changing the primary care delivery system as a whole [80]. A systematic review correlated to pharmacist- led DM self-management Education (DSME) studies also indicated a significant improvement in medication adherence, quality of life, and diabetes knowledge after DSME [81].

In a systematic review of non-dispensing pharmaceutical services in low- and middle-income countries, Pande et al. (2013) found that “pharmaceutical care” was the most prevalent language used in the studies, and the majority of the interventions involved simple patient education [82].

Although the main services were implemented either more specific, such as improving HRQoL/QoL, managing and controlling diseases, increasing medication adherence, resolving DRPs, or TRPs. The effectiveness of CPS delivered in primary care clinics was evaluated in a systematic review, and the majority of the complex and comprehensive interventions, such as physical assessment, monitoring, prescribing, and face-to-face communication with physicians, were conducted in high-income countries [83]. Undoubtedly, the majority of congestive heart disease (CHD) seems to be closely related to abnormal BP, diabetes, and dyslipidemia [84], in which several studies have been shown the effective role of pharmacists in reducing morbidity and mortality associated with CHD, as well as numerous articles have been identified that cooperation, especially cooperation between physicians and pharmacists, can effectively reduce the incidence of drug-related problems and improve outcomes very favorably in some clinical situations [85‐87].

The need for knowledgeable, proficient, and experienced healthcare practitioners has grown year after year and the role of a clinical pharmacist has expanded to encompass all phases of patient care as part of the healthcare team. A study looking at physicians, nurse practitioners, and physician assistants estimated a shortage of qualified oncology and Hematology practitioners by 2020 [88]. Because of their special knowledge and extensive training, oncology pharmacists are perfectly positioned to deliver high-quality care to cancer patients and offset some of the shortage of practitioners [89]. Another study conducted in the Hematological and Has Unit revealed that the inclusion of a clinical pharmacist in the hemodialysis unit resulted in the detection and treatment of several DRPs. The majority of the interventions were important, and they may have resulted in improved therapeutic outcomes [90]. Additionally, other studies conducted in diabetes clinics have documented the diabetes management of patients whose drug therapy was managed specifically by clinical pharmacists under physician supervision. The studies showed consistent, favorable results on glycemic control in the university-affiliated out-patient clinic, Veterans Affairs medical centers, and managed care settings [91‐94].

The existence, accessibility, and inference of hospital pharmacists need to be improved, and physicians should be more aware of what they can offer, as shown in our scoping review. Qualitative semi-structured interviews revealed that the presence, visibility, and implication of hospital pharmacists need to be improved, and physicians should be more aware of what they can offer, according to qualitative semi-structured interviews. As a result, trust is one of the most important factors for improving physician–pharmacist collaboration, as numerous studies discovered [95‐97]. Trust is critical for physician–pharmacist collaboration and has been linked to greater commitment and dialogue.

According to our analysis, we attempted to identify elements that could either encourage or hinder the introduction of pharmaceutical care services in Middle Eastern countries. Hence, we found only a few studies that reported some factors, including a limited number of clinical pharmacists, lack of cooperation between pharmacists/ clinical pharmacists and health care professionals, low variable socioeconomic status, and lack of expert and trained pharmacists. A study reported that the identification of barriers and facilitators of implementation is one among the foremost important and feasible strategies to implement change. Therefore, the identification of influencing factors employing a framework, like APOTECA, could guide the development of a multifaceted, multilevel tailored plan, using implementation strategy tools, to a successful implementation of CPS [98].

The cost-effectiveness of pharmaceutical care interventions aims either to reduce medication errors or to reduce the cost of medication-related morbidity and mortality. As a result, there is a great opportunity for pharmacists to have a significant impact on reducing healthcare costs because they have the expertise to identify, correct, and prevent medication errors and medication-related problems. For this reason, two studies have examined the cost-effectiveness of clinical pharmacists providing services in a general practice (GP) [99, 100]. Pharmacist intervention dominated, decreased costs, and improved health outcomes, according to the Canadian Cancer Society in Canada [101]. In a study conducted in the United Kingdom, pharmacist intervention was found to be more cost-effective than conventional care [102].

Because not all Middle Eastern countries were covered in the scoping review, there are certain limitations on how far the influence of pharmaceutical care services may be generalized. Additionally, we were unable to examine pharmaceutical care services in various Middle Eastern nations due to a lack of research and other nations’ rejection of interventions. While some research emphasized the value of cost-effectiveness, the majority of studies conducted in the Middle East did not, which may be one of the challenges to accessing pharmaceutical therapy.

To sum up, this scoping review showed that Clinical pharmacist’s/ pharmacists’ interventions in different general practices have a significant role in improving healthcare outcomes, including QoL, medication adherence, mortality rate, hospital readmission, and hospitalization, reviewing patients’ medication discrepancies, and DRPs. These data can be used to design a strategy that identifies the factors that assure the continuation of pharmaceutical services as well as the issues that hinder this continuity. Furthermore, it may be possible to provide these services in nations where Pharmaceutical Care Services are not unified, thus consider including them.