Sensitivity of Patient Outcomes to Pharmacist Interventions. Part I: Systematic Review and Meta-Analysis in Diabetes Management

University of Toronto, Toronto, Ontario, Canada
Annals of Pharmacotherapy (Impact Factor: 2.06). 10/2007; 41(10):1569-82. DOI: 10.1345/aph.1K151
Source: PubMed


Pharmacists participate in managing diabetes therapy. Despite many reviews, few have quantified the impact of pharmacists' interventions.
To identify outcomes sensitive to pharmacists' interventions and quantify their impact through critical literature review.
All original research describing the impact of pharmacists' interventions in the management of diabetic pharmacotherapy was sought in International Pharmaceutical Abstracts, MEDLINE, Embase, Cochrane Register, and Cumulative Index to Nursing & Allied Health Literature from inception through 2006. Two independent reviewers identified articles, compared results, and settled differences through consensus. The Downs-Black scale was used to assess quality. Data included intervention type, patient numbers, demographics, study characteristics, instruments used, data compared, and outcomes reported. A random-effects meta-analysis combined amenable results.
Of 302 articles identified, 108 involved pharmacists' interventions; 36 addressed diabetes (14 medical clinics, 11 community pharmacies, 7 ambulatory care clinics, 4 hospital wards, 1 physician's office, 1 prison, and 3 in both medical clinics and community pharmacies; 1 did not describe its practice site). Research designs included randomized (n = 18) and nonrandomized (n = 9) controlled trials, pre- and postobservational cohorts (n = 2), retrospective cohort study (n = 1), chart reviews (n = 5), and database study (n = 1). Diabetes education (69%) and medication management (61%) were the most frequently used interventions. Mean +/- SD quality was 62 +/- 11% (fair). Fifty-one (69%) study results were sensitive. Meta-analysis of data from 2247 patients in 16 studies found a significant reduction in hemoglobin A1C (A1C) levels in the pharmacists' intervention group (1.00 +/- 0.28%; p < 0.001) but not in controls (0.28 +/- 0.29%; p = 0.335). Pharmacists' interventions further reduced A1C values 0.62 +/- 0.29% (p = 0.03) over controls.
A1C is sensitive to pharmacists' interventions. Several potentially sensitive outcomes were identified, but too few studies were available for quantitative summaries. More research is needed.

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Available from: Jana Bajcar, Mar 28, 2014
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    • "Regarding medication adherence, the pharmacist could play a particular role in education programs. Dedicated studies have shown a moderate positive effect of programs involving pharmacists on metabolic control but the effects on adherence were also mixed.40,41 The adherence to treatment or to activities related to lifestyle (diet, physical activity) is generally not assessed as such, but is integrated into self-management behaviors or self-care activities, although overall positive results of educational intervention studies of self-management behaviors have been reported in diabetes.22 "
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    ABSTRACT: While therapeutic patient education is now recognized as essential for optimizing the control of chronic diseases and patient well-being, adherence to treatment and medical recommendations is still a matter of debate. In type 2 diabetes, the nonadherence to therapy, estimated at more than 40%, is perceived as a barrier for improving the prognosis despite recent therapeutic advances. Interventional studies have barely begun to demonstrate the effectiveness of technical and behavioral actions. The aim of this review is to question the concept of adher-ence in terms of therapeutic education based on quantitative and qualitative data. The research on therapeutic education has shown the effectiveness of structured actions in type 2 diabetes, but adherence is rarely an end point in randomized trials. A positive but inconsistent or moderate effect of education actions on adherence has been shown in heterogeneous studies of varying quality. Program types, outlines, theoretical bases, and curricula to set up for action effectiveness are still being discussed. Qualitative studies, including sociological studies, provide a useful and constructive focus on this perspective. Adherence is a soft and flexible tool available to the patient in his/her singular chronic disease trajectory, and as such, integrates into individual therapeutic strategies, including socio-cultural interactions, beyond the medical explanation of the disease and the patient. Four key elements for the development of structured therapeutic education are discussed: 1) the access to health literacy, 2) the contextualization of education activities, 3) the long-term chronic dimension of self-management, and 4) the organizational aspects of health and care. Rather than focusing the objective on behavioral changes, structured therapeutic education actions should attempt to provide tools and resources aimed at helping individuals to manage their disease in their own context on a long-term basis, by developing health literacy and relational and organizational aspects of the health professionals and system.
    Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 07/2014; 7:357-367. DOI:10.2147/DMSO.S36369
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    • "These specialist clinics tend to focus very much on respiratory disorders of sleep and are considered as tertiary centres which treat later stage or more severe sleep disorders only. Community pharmacists are already in a suitable position to initiate conversation, discuss medicines, and provide ongoing follow-up [3] related to a range of health problems, and many interventions have been implemented for other chronic health problems such as asthma [4-8], diabetes [9-11] and hypertension [12,13]. There are many similarities between these chronic health problems and sleep disorders in terms of early intervention, community-level management and continuing care provision. "
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    ABSTRACT: Sleep disorders are very common in the community and are estimated to affect up to 45% of the world's population. Pharmacists are in a position to give advice and provide appropriate services to individuals who are unable to easily access medical care. The purpose of this study is to develop an intervention to improve the management of sleep disorders in the community. The aims are- (1) to evaluate the effectiveness of a community pharmacy-based intervention in managing sleep disorders, (2) to evaluate the role of actigraph as an objective measure in monitoring certain sleep disorders and (3) to evaluate the extended role of community pharmacists in managing sleep disorders. This intervention is developed to monitor individuals undergoing treatment and overcome the difficulties in validating self-reported feedback.Method/design: This is a community-based intervention, prospective, controlled trial, with one intervention group and one control group, comparing individuals receiving a structured intervention with those receiving usual care for sleep-related disorders at community pharmacies. This study will demonstrate the utilisation and efficacy of community pharmacy-based intervention to manage sleep disorders in the community, and will assess the possibility of implementing this intervention into the community pharmacy workflow.Trial registration: Australian New Zealand Clinical Trial Registry: ACTRN12612000825853.
    BMC Health Services Research 02/2014; 14(1):74. DOI:10.1186/1472-6963-14-74 · 1.71 Impact Factor
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    • "General practitioners (GPs) and community pharmacists are increasingly being encouraged to adopt more collaborative approaches to health care delivery as collaboration between GPs and pharmacists has been shown to be an effective means of improving patient care by helping patients achieve therapeutic goals [3-5] and enhancing medication management [6-8]. Research to date has tended to focus on the effect of GP-pharmacist collaboration on patient outcomes [9-11]. Limited attention has been paid to GP and pharmacist attitudes towards collaboration. "
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    ABSTRACT: Background Community Pharmacists and General Practitioners (GPs) are increasingly being encouraged to adopt more collaborative approaches to health care delivery as collaboration in primary care has been shown to be effective in improving patient outcomes. However, little is known about pharmacist attitudes towards collaborating with their GP counterparts and variables that influence this interprofessional collaboration. This study aims to develop and validate 1) an instrument to measure pharmacist attitudes towards collaboration with GPs and 2) a model that illustrates how pharmacist attitudes (and other variables) influence collaborative behaviour with GPs. Methods A questionnaire containing the newly developed “Attitudes Towards Collaboration Instrument for Pharmacists” (ATCI-P) and a previously validated behavioural measure “Frequency of Interprofessional Collaboration Instrument for Pharmacists” (FICI-P) was administered to a sample of 1215 Australian pharmacists. The ATCI-P was developed based on existing literature and qualitative interviews with GPs and community pharmacists. Principal Component Analysis was used to assess the structure of the ATCI-P and the Cronbach’s alpha coefficient was used to assess the internal consistency of the instrument. Structural equation modelling was used to determine how pharmacist attitudes (as measured by the ATCI-P) and other variables, influence collaborative behaviour (as measured by the FICI-P). Results Four hundred and ninety-two surveys were completed and returned for a response rate of 40%. Principal Component Analysis revealed the ATCI-P consisted of two factors: ‘interactional determinants’ and ‘practitioner determinants’, both with good internal consistency (Cronbach’s alpha = .90 and .93 respectively). The model demonstrated adequate fit (χ2/df = 1.89, CFI = .955, RMSEA = .062, 90% CI [.049-.074]) and illustrated that ‘interactional determinants’ was the strongest predictor of collaboration and was in turn influenced by ‘practitioner determinants’. The extent of the pharmacist’s contact with physicians during their pre-registration training was also found to be a significant predictor of collaboration (B = .23, SE = .43, p <.001). Conclusions The results of the study provide evidence for the validity of the ATCI-P in measuring pharmacist attitudes towards collaboration with GPs and support a model of collaboration, from the pharmacist’s perspective, in which collaborative behaviour is influenced directly by ‘interactional’ and ‘environmental determinants’, and indirectly by ‘practitioner determinants’.
    BMC Health Services Research 09/2012; 12(1):320. DOI:10.1186/1472-6963-12-320 · 1.71 Impact Factor
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