Review Article
Pharmacist services provided in general practice clinics: A systematic review and meta-analysis

https://doi.org/10.1016/j.sapharm.2013.08.006Get rights and content

Abstract

Background

Integration of pharmacists into primary care general practice clinics has the potential to improve interdisciplinary teamwork and patient care; however this practice is not widespread.

Objective

The aim of this study was to review the effectiveness of clinical pharmacist services delivered in primary care general practice clinics.

Methods

A systematic review of English language randomized controlled trials cited in the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and International Pharmaceutical Abstracts was conducted. Studies were included if pharmacists had a regular and ongoing relationship with the clinic; delivered an intervention aimed at optimizing prescribing for, and/or medication use by, clinic patients; and were physically present within the clinic for all or part of the intervention, or for communication with staff. The search generated 1484 articles. After removal of duplicates and screening of titles and abstracts against inclusion criteria, 131 articles remained. A total of 38 studies were included in the review and assessed for quality. Seventeen studies had common endpoints (blood pressure, glycosylated hemoglobin, cholesterol and/or Framingham risk score) and were included in meta-analyses.

Results

Twenty-nine of the 38 studies recruited patients with specific medical conditions, most commonly cardiovascular disease (15 studies) and/or diabetes (9 studies). The remaining 9 studies recruited patients at general risk of medication misadventure. Pharmacist interventions usually involved medication review (86.8%), with or without other activities delivered collaboratively with the general practitioner (family physician). Positive effects on primary outcomes related to medication use or clinical outcomes were reported in 19 studies, mixed effects in six studies, and no effect in 13 studies. The results of meta-analyses favored the pharmacist intervention, with significant improvements in blood pressure, glycosylated hemoglobin, cholesterol and Framingham risk score in intervention patients compared to control patients.

Conclusions

Pharmacists co-located in general practice clinics delivered a range of interventions, with favorable results in various areas of chronic disease management and quality use of medicines.

Introduction

General practice is defined as “the provision of primary continuing comprehensive whole-patient medical care to individuals, families and their communities”.1 In the provision of primary care, much undifferentiated illness is seen; the primary care physician or general practitioner (GP) must deal with problem complexes and make a total assessment of a patient's condition in a range of clinical contexts. In managing the patient, general practice staff may make referral to other health care professionals and community services, including pharmacists.1

There is evidence that non-dispensing or clinical services provided by pharmacists in the outpatient setting may result in improved patient outcomes and prescribing patterns.2 Despite this, the uptake of these services is low and collaboration between pharmacists and general practitioners is suboptimal.3, 4 Limitations of most models of GP-pharmacist collaboration in primary care include geographical isolation, poor communication, and lack of time and remuneration for team activities.5, 6

In recent years, pharmacists have increasingly integrated into general practice clinics.7, 8 Practice pharmacists have a range of functions including administrative and clinical duties related to their expertise in medication use and safety. Clinical services provided by these pharmacists include drug information, medication reviews, education and counseling, health promotion, and running disease management clinics.9 The co-location of pharmacists with GPs in these settings has been shown to enable greater inter-professional communication and the development of collaborative working relationships.10

A systematic review by Fish et al11 published in 2002 found that studies of general practice-based pharmaceutical services have largely been of poor methodological quality, with inconsistent results. Since that review was published, there has been a rise in the number of studies exploring the role of general practice-based pharmacists.

Other more recent systematic reviews of pharmacist interventions have focused on specific patient groups, disease states, interventions, and/or outcome measures in a diverse range of health care settings rather than in primary care general practice clinics specifically, thus making it difficult to apply findings to the general practice setting.2, 12, 13, 14, 15

The aim of the current systematic review was to evaluate the role of pharmacists co-located with GPs and other health professionals within primary care general practice clinics (e.g. family practice clinics, community health centers or primary health care centers). The review includes randomized controlled trials (RCTs) that explored a variety of pharmacist interventions covering different disease states and patient groups, and their effect on various health outcomes.

Section snippets

Search strategy

A search of the literature was undertaken using the Cochrane Central Register of Controlled Trials (CENTRAL) (1966 – May 2013), MEDLINE (1966 – May 2013), EMBASE (1966 – May 2013) and International Pharmaceutical Abstracts (IPA) (1970 – May 2013). In CENTRAL and MEDLINE, Medical Subject Headings (MeSH) related to pharmacy (“pharmacists” or “pharmaceutical services”) and general practice (“family practice” or “primary health care” or “family physicians” or “physicians' offices” or “community

Search and study selection

The electronic database searches retrieved 1484 articles. An additional eight articles were identified by a manual search of relevant review articles and reference lists. After removal of duplicates, the titles and abstracts of 986 studies were reviewed, of which 855 were excluded because they clearly did not meet the inclusion criteria. 131 articles were deemed suitable for the retrieval of full-text copies for further scrutiny; 93 of these were excluded after review by at least two

Discussion

This systematic review and meta-analysis evaluated RCTs that investigated clinical services delivered by pharmacists co-located in general practice clinics. Findings from this review highlight the benefits of interprofessional communication and collaboration that occur with co-location.

Most studies (25/38) reported positive effects on at least one primary outcome measure. Positive effects were more often seen in studies that involved a pharmacist delivering a multifaceted intervention in

Conclusion

Pharmacists co-located in primary care general practice clinics delivered a variety of interventions, with favorable results seen in the management of cardiovascular disease, diabetes and some measures of quality use of medicines. Interventions were most effective when they were multifaceted and involved interprofessional collaboration with face-to-face communication. Co-location of pharmacists within general practice clinics may be an effective approach for delivery of patient-centered

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    Conflict of interest: None.

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