The effect of using pharmacists to provide services other than medicine dispensing in low- and middle-income countries

Researchers in The Cochrane Collaboration conducted a review to evaluate the effect of using pharmacists to provide services other than medicine dispensing in low- and middle-income countries. After searching for all relevant studies, they found 12 studies that met their requirements. Their findings are summarised below.

The use of pharmacists to provide services other than dispensing medication

Traditionally, the main role of the pharmacist has been to prepare and dispense medicines. Recently, however, the number of tasks that are expected of them has grown.They are now often expected to make sure that patients use their medicines properly, help patients solve medicine-related problems and to give health information that can help patients improve their health. 

All of the studies in this review took place in middle income countries, either at outpatient departments, community pharmacies or primary healthcare centres.

In 11 of the studies, pharmacists gave education and counselling to patients with chronic illnesses such as asthma and diabetes. Pharmacists gave the patients information about how to use their medicines properly and about possible side effects of the medicines, and helped them to identify and solve problems with their medicines. They also gave the patients information about the disease and advice about self-management and the importance of a healthy lifestyle. The patients who were given these services were compared to patients who were given the usual pharmacist services without education or counselling.

In one study, pharmacists gave education to general practitioners (GPs) about care of children with asthma. These GPs were compared to GPs who were given usual pharmacist services.

No studies were found where pharmacist-provided services were compared to the services provided by other health workers.

What happens when pharmacists provide services other than dispensing medication?

When pharmacists give education and counselling to patients with chronic illnesses:

· patients may experience small improvements in health outcomes such as blood pressure levels and glucose levels (low quality evidence),

· patients may use health services less (for instance fewer visits to the doctor, fewer stays in hospital) (low quality evidence),

· patients probably experience small improvements in quality of life (moderate quality evidence),

· patients’ medication costs may be lower (low quality evidence).

When pharmacists give education and counselling about asthma care to GPs:

· their patients may experience slightly fewer asthma symptoms (low quality evidence).

Authors' conclusions: 

Pharmacist-provided services that target patients may improve clinical outcomes such as management of high glucose levels among diabetic patients, management of blood pressure and cholesterol levels and may improve the quality of life of patients with chronic conditions such as diabetes, hypertension and asthma. Pharmacist services may reduce health service utilisation such as visits to general practitioners and hospitalisation rates. We are uncertain about the effect of educational sessions by pharmacists for healthcare professionals due to the imprecision of a single study included in this review. Similarly, conclusions could not be drawn for health service utilisation and costs due to lack of evidence on interventions delivered by pharmacists to healthcare professionals. These results were heterogenous in the types of outcomes measured, clinical conditions and approaches to measurement of outcomes, and require cautious interpretation. All eligible studies were from middle income countries and the results may not be applicable to low income countries.

Read the full abstract...
Background: 

The role of pharmacists has expanded beyond dispensing and packaging over the past two decades, and now includes ensuring rational use of drugs, improving clinical outcomes and promoting health status by working with the public and other healthcare professionals.

Objectives: 

To examine the effect of pharmacist-provided non-dispensing services on patient outcomes, health service utilisation and costs in low- and middle-income countries.

Search strategy: 

Studies were identified by electronically searching the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (February 2010), MEDLINE (1949 to February 2010), Scopus (1960 to March 2010) and International Pharmaceutical Abstracts (1970 to January 2010) databases. An update of this review is currently ongoing. The search was re-run September 2012 and the potentially relevant studies are awaiting classification.

Selection criteria: 

Randomised controlled trials, non-randomised controlled trials, controlled before-after studies and interrupted time series analyses comparing 1. pharmacist-provided non-dispensing services targeted at patients versus (a) the same services provided by other healthcare professionals, (b) the same services provided by untrained health workers, and (c) usual care; and 2. pharmacist-provided non-dispensing services targeted at healthcare professionals versus (a) the same services provided by other healthcare professionals, (b) the same services provided by untrained health workers, and (c) usual care in low- and middle-income countries. The research sites must have been located in low or middle income countries according to World Bank Group 2009 at the time of the study, regardless of the location or the origin of the researchers.            

Data collection and analysis: 

Two authors independently reviewed studies for inclusion in the review. Two review authors independently extracted data for each study. Risk of bias of the included studies was also assessed independently by two authors.

Main results: 

Twelve studies comparing pharmacist-provided services versus usual care were included in this review. Of the 12 studies, seven were from lower middle income countries and five were from upper middle income countries. Eleven studies examined pharmacist-provided services targeted at patients and one study evaluated pharmacist interventions targeted at healthcare professionals. Pharmacist-provided services targeting patients resulted in a small improvement of clinical outcomes such as blood pressure (-25 mm Hg/-6 mm Hg and -4.56 mm Hg/-2.45 mm Hg), blood glucose (-39.84 mg/dl and -16.16 mg/dl), blood cholesterol (-25.7 mg/dl)/ triglyceride levels (-80.1 mg/dl) and asthma outcomes (peak expiratory flow rate 1.76 l/min). Moreover, there was a small improvement in the quality of life, although four studies did not report the effect size explicitly. Health service utilisation, such as rate of hospitalisation and general practice and emergency room visits, was also found to be reduced by the patient targeted pharmacist-provided services. A single study examined the effect of patient targeted pharmacist interventions on medical expenses and the cost was found to be reduced. A single study that examined pharmacist services that targeted healthcare professionals demonstrated a very small impact on asthma symptom scores. No studies assessing the impact of pharmacist-provided non-dispensing services that targeted healthcare professionals reported health service utilisation and cost outcomes. Overall, five studies did not adequately report the numerical data for outcomes but instead reported qualitative statements about results, which prevented an estimation of the effect size.

Studies for the comparison of patient targeted services provided by pharmacists versus the same services provided by other healthcare professionals or untrained healthcare workers were not found. Similarly, studies for the comparison of healthcare professional targeted services provided by pharmacists versus the same services provided by other healthcare professionals or untrained healthcare workers were not found.

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