Systematic Review Compares Pharmacist-Led Care to Usual Care for Chronic Disease Management
The integration of clinical pharmacists in patient care may offer increased access to healthcare and improved patient outcomes. Recently introduced legislation would establish pharmacists as healthcare providers and enable coverage of pharmacists' services through Medicare Part B in medically underserved communities. Since 1995, VA has allowed clinical pharmacy specialists an expanded scope of practice, with independent prescribing privileges. This systematic review sought to determine the effectiveness and harms of pharmacist-led chronic disease management for community-dwelling adults. Investigators searched the literature from 1995 through February 2016, and then analyzed data from 72 articles representing 63 studies, including 40 randomized controlled trials. For the most part, studies assessed intermediate outcomes, such as blood pressure (BP), cholesterol, or glucose goal attainment in patients with hypertension, cardiovascular disease, or diabetes (45 of 65 unique studies). Investigators also assessed whether there were common intervention components or processes that led to improved outcomes.
- Compared with usual care, pharmacist-led care was associated with similar numbers of office visits, urgent care or emergency department visits, and hospitalizations (moderate-strength evidence), as well as medication adherence (low-strength evidence).
- Compared with usual care, pharmacist-led care increased the number or dose of medications received and improved glycemic, BP, and lipid goal attainment (moderate-strength evidence).
- Mortality and clinical events were similar between patients in usual care versus pharmacist-led care (low-strength evidence). Evidence on patient satisfaction was mixed and insufficient.
- The most common intervention components were medication monitoring (89% of studies), disease self-care and support (82%), medication therapy review (52%), and prescribing authority (51%), but no consistent association could be made between specific components and improved outcomes.
- Pharmacist-led chronic disease management was associated with effects similar to those of usual care for resource utilization and may improve physiologic goal attainment. Further research is needed to determine whether increased medication use and goal attainment improve outcomes.
- Studies were typically short-term and were designed to assess physiologic intermediate outcomes rather than clinical events.
- Reporting of many clinical outcomes of interest was limited.
- The majority of studies were from non-VA settings, and the usual care comparator may have differed compared to VA usual care, which includes an integrated electronic health record system and focus on chronic illness management in primary care.
This study was funded through VA HSR&D's Quality Enhancement Research Initiative (QUERI) and the Evidence-based Synthesis Program (ESP). Drs. Greer, Rector, and Wilt and Mr. MacDonald are part of HSR&D's Center for Chronic Disease Outcomes Research, Minneapolis, MN.
Greer N, Bolduc J, Geurkink E, Rector T, Olson K, Koeller E, MacDonald R, and Wilt TJ. Pharmacist-led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared with Usual Care. Annals of Internal Medicine. April 26, 2016; Epub ahead of print.