NES Evidence Search & Summary · NES Evidence Search & Summary ... Assistant Director of Pharmacy,...

NES Evidence Search & Summary

Patient counselling for prescribed medication

Peta Broadfoot, Kirsten MacLeod, Paul Manson & Siobhán O’Brien NHS Grampian Library & Knowledge Services


[2]

Introduction ................................................................................................................ 3

Key findings ................................................................................................................ 4

Background ................................................................................................................ 6

Review question ......................................................................................................... 7

Methodology ............................................................................................................... 7

Summary of Evidence ................................................................................................ 8

General comments .................................................................................................. 8

Summary of included studies .................................................................................. 9

Detailed review questions ..................................................................................... 13

Evidence Gaps ......................................................................................................... 16

References ............................................................................................................... 17

Appendix A: Search Strategies ................................................................................ 20

Appendix B: Details of included studies ................................................................... 24

Note

This review was commissioned by NHS Education for Scotland as part of its Evidence

Search & Summary project, and produced by staff of the Library & Knowledge Services at

NHS Grampian. Although the evidence has been sourced and compiled systematically, it is

not a systematic review. This review summarises relevant evidence from pre-appraised

studies in systematic reviews; it does not make recommendations.


[3]

Introduction

Community pharmacy services in Scotland are undergoing a change of practice

whereby pharmacists will become more involved in the front-line delivery of health

care by giving advice and assistance to patients. Counselling patients when

dispensing prescription medications gives pharmacists the opportunity to ensure

patients understand the purpose of their medications, their implications, and

restrictions. Pharmacists may have the opportunity to repeat important messages

and patients may be more forthcoming about their actual medication adherence than

in a GP consultation.

NHS Education for Scotland (NES) Pharmacy Services conducted an exercise with

community pharmacists to determine their readiness for new services. Patient

counselling and the increased interaction with patients was one of the areas

highlighted as being of concern.

A summary of the evidence relating to patient counselling was requested by the

Assistant Director of Pharmacy, NES, in order to inform the implementation of these

services. The review question was:

What literature exists on the format, content, and efficacy of patient counselling by pharmacists? What are pharmacists’ experiences of patient counselling and what skills or training do they need? What are the patients’ experiences of counselling?

A search of key resources was made in January 2015. The search was restricted to

systematic reviews in order to use only previously-appraised studies.


[4]

Key findings

General

• There was limited systematic evidence to answer the review question.

• The methodology of primary studies was reported as being generally poor.

Format, content and efficacy of counselling

• Format

o Written information to back up verbal information was recommended

but it was less useful on its own.

• Content

o The consensus content included

� name of the drug

� purpose

� importance

� dosage regime

� administration

� duration of therapy

� potential interactions

• Efficacy

o There was mixed evidence on the effectiveness of interventions that

included pharmacist counselling, though it appeared to have some

positive effect on outcomes.

o Improvements in outcomes were not always statistically or clinically

significant.

o The effect of counselling itself could often not be separated in

multi-part interventions.

Pharmacists’ experience of counselling

• Pharmicists found it professionally rewarding to take part in extended

Medication Therapy Management services, which included patient

counselling.

• Pharmacy working practices may have to be changed to free pharmacists’

time for counselling services.


[5]

Skills or training required by pharmacists for counselling

• There was no systematic evidence on the skills and training required for

counselling.

Patients’ experiences of counselling

• Counselling can increase patients’ awareness of the importance of their

medication.

• Patients wanted to know about side effects.

• Barriers to communication need to be considered.

• Patients were concerned about getting conflicting information from

pharmacists and other healthcare professionals.

• There was weak evidence that counselling improved patients' clinical and

humanistic outcomes


[6]

Background

Community pharmacy services in Scotland are undergoing a change of practice

whereby pharmacists will become more involved in the front-line delivery of health

care rather than simply dispensing prescriptions. The new pharmacy contract has

moved from quantitative measures such as numbers of prescriptions fulfilled to

qualitative measures of service. Pharmacists will be expected to give more advice

and assistance to patients.

Pharmacists already have a mental list of ‘trigger medications’ that prompt them to

speak to the patient to ensure they understand their implications or restrictions (e.g.,

ensuring a woman taking hormonal contraception is not also on antibiotics as they

can interfere with its efficacy). The new services will extend that interaction. This is

particularly important for older patients or those with multiple morbidities as they may

be taking several medications. The increase in preventative medication, e.g., statins

to reduce cholesterol or aspirin to reduce the risk of thrombosis, will also increase

the potential for harmful drug interactions.

In addition to preventing drug interactions, pharmacists can:

• advise on medication regimens that minimise undesirable effects for the patient (e.g., anti-hypertensive medications make you need the toilet so patients shouldn’t take them before they go to bed)

• make sure patients understand why they are taking medications

• identify the most important medications for a patient to take – this might not be obvious to the patient as they don’t feel any immediate benefit from taking it (e.g., statins which reduce heart attack risk in the long-term)

Pharmacists may benefit from seeing patients regularly as they collect repeat

prescriptions so they will have the opportunity to repeat messages in a more relaxed

atmosphere than a GP consultation. Patients are also more willing to be honest with

the pharmacist regarding their adherence to their medication (“I have these ten

tablets but I only take six of them ...”).

In response to these changes NES Pharmacy Services conducted a DELPHI

exercise with community pharmacists to determine their readiness for the new

services. Patient counselling and the increased interaction with patients was one of

the areas highlighted as being of concern.


[7]

Review question

The enquiry was recast as four separate but linked questions, in the context of adult

patients receiving prescription medication from a community pharmacist:

• What literature exists on the format, content, and efficacy of patient

counselling by pharmacists?

• What are pharmacists’ experiences of patient counselling?

• What skills and/or training do pharmacists need for effective counselling?

• What are the patients’ experiences of counselling?

Methodology

A search was conducted on key resources (Medline, Embase, CINAHL, Cochrane

Library, Epistemonikos) for literature on counselling by pharmacists. The search

strategy included terms to identify pharmacies/pharmacists, patient

counselling/education, and prescription drugs. The detailed search strategies are in

Appendix A. The study type was limited to systematic reviews as they provided an

effective summary of the evidence and individual studies did not have to be

appraised by non-specialists. The results were limited to English language.

The results were screened on title and abstract by two reviewers. Studies that were

potentially relevant were obtained in full-text and screened by two reviewers and the

final selection made. Disagreements at either stage were resolved by a third

reviewer. The inclusion criteria from the review question were:

Population Adult patients recieving prescription medication (not carers, parents or proxies)

Intervention Counselling by pharmacist at time of dispensing

Situation Community pharmacies

Location Any Westernised health service

Date range 2004 – present

Study design Systematic review

Table 1: Inclusion criteria for studies

A total of 164 studies were found

duplicates, 155 studies were

forward to be screened on full

screening on full-text content,

For each of the four review questions, d

responsible for one question

Summary of Evidence

General comments

Most evidence was drawn from systematic reviews of controlled trials, some of them

randomised. Two other reviews drew on surveys of practice

included studies (Table 2) note

surveys of practice.

There were only two systematic

itself (8, 10). One assessed the effects of

the other investigated verbal counselli

for prescription medicines in community pharmacies

adherence as the desired outcome and the counselling interview was one of the

interventions included. Many interventions were

164 studies identified in

screened on title & abstract

52 studies screened on full


[8]

A total of 164 studies were found in the literature searches. After removing

studies were screened on title and abstract. Fifty-two

full-text. Copies of all studies were obtained.

content, 12 studies were included in the review.

For each of the four review questions, data was extracted by a single reviewer

question, using a standardised form.

Summary of Evidence


randomised. Two other reviews drew on surveys of practice(9,10). The summary of

notes where they are drawn on systematic reviews of

systematic reviews that addressed the counselling interview

One assessed the effects of pharmacist-led patient counseling

the other investigated verbal counselling rates and/or types of information provided

for prescription medicines in community pharmacies (10). Most reviews had improved


interventions included. Many interventions were multi-part and it was difficult to

164 studies identified in searches

155 unique studies screened on title & abstract

52 studies screened on full text

12 studies included in review


removing

two studies went

ll studies were obtained. After

included in the review.

a single reviewer, each


. The summary of

on systematic reviews of

reviews that addressed the counselling interview

led patient counseling (8) and

ng rates and/or types of information provided

Most reviews had improved


part and it was difficult to


[9]

isolate the effectiveness of any one part. The nature of the counselling interview

was not given in detail, though it appeared that it was generally more structured than

an impromptu disussion at the time of dispensing.

The systematic review authors observed that in general the methodology of the

primary studies was poor, with low particpant numbers, short follow up, lack of detail

on the interventions, and a strong risk of bias or cross-contamination between study

arms. The control groups often had high adherence rates at the start of the study,

perhaps due to being well motivated to take part, making it difficult to show signficant

improvement. Due to considerable heterogenity in population, study design and

adherence measures, the systematic reviews gave their results as a narrative

analysis rather than a meta-analysis.

Summary of included studies

The outline charcteristics of the included studies are given in Table 2. The detailed

characteristics are in Appendix B.


[10]

Country Setting Intervention Outcomes Comments

1. Banning (2009) Not specified Hospital & community

• Behavioural

• Information/education

• Health professional involvement

• Monitoring medication-related outcomes

Medication adherence

Pharmacy involvement was beneficial though not all pharmacist-led interventions were effective. Pharmacist-led teaching was effective but general education interventions were not.

2. Cutrona (2010) Not specified Hospital & community

• Person-independent interventions (mail, electronic)

• Person-dependent interventions (face-to-face, telephone)


5 of 6 community pharmacist-led intereventions increased adherence.

3. George (2008) Not specified Hospital & community

• Patient education

• Behavioural strategies


Individual patient education was most effective. Elderly patients reported poor communication and conflicting information from health professionals including pharmacists.

4. Higgins (2004) Not specified Hospital & community

• Patient education

• Behavioural strategies


Combined interventions were more effective than single ones. Education interventions varied considerably and had mixed success.


[11]


5. Holland (2008) Not specified Hospital, community & home

Pharmacist-led medication review

Hospital admission All-cause mortality

Patients had an increased knowledge of their medication but this did not affect the outcomes.

6. Nieuwlaat (2014) Not specified Hospital & community

Any intervention to improve adherence including education, family support, reminders, etc.


Little evidence of enhanced adherence or improved clinical outcomes.

7. Nkansah (2010) ‘Westernised’ systems

Community & out-patient

Review of pharmacists non-dispensing roles

Health related Results supported pharmacists role in education and therapy.

8. Okumura (2014) Not specified Hospital & community

Review of the structure, processes and technical contents of pharmacist counselling or education

Clinical, humanistic, and economic measures

Drug-related morbidity reduced and, humanistic outcomes (e.g., QOL) improved; very little information on economic outcomes.

9. Oladapo (2012) USA Community & out-patient

Review of Medication Therapy Management (MTM) programmes This is a survey of practice.

Rates of MTM provision, attitudes of providers and physicians.

MTM services go beyond patient counselling. Pharmacists need to have time to operate MTM, e.g. by technicians taking on additional roles.

10. Puspitasari (2009)

Not specified Community Patient counselling This is a survey of practice.

Counselling rates Type of information given

Counselling rates varied from 8-100%. Recommendations given for information to be included in counselling.


[12]


11. Schlenk (2008) Not specified Community • Education

• Memory aids


Half of studies of educational interventions showed significant improvement in outcomes. Tailored and ongoing interventions seemed more effective than brief interventions.

12. Thomas (2014) OECD countries

Hospital (10) & community (10)

Pharmacist-led:

• Medication review

• Counselling

• Home visits

• Telephone support

Unplanned hospital admission

3 of 10 community studies took place in the pharmacy, others were in the home or surgery. No reductions in unplanned admissions were recorded.

Table 2: Summary of included studies


[13]

Detailed review questions

What literature exists on the format, content and efficacy of patient

counselling?

There was little systematic evidence on the format of patient counselling; even a

review explicity designed to gather data on the structure and process of pharmacist

counselling found that the format and content of counselling were poorly reported(8).

Most reviews were investigating the efficacy of counselling while others included

surveys(10) or a broad range of qualitative and quantitative studies(1). One review

identified the need for counselling to take place in private, confidential, and

comfortable surroundings(10). Few studies actually took place in community

pharmacies (for example, 18/101 studies in Okumura(8)).

Recommendations on the content were integrated from American and Austrailian

guidelines(10) and earlier RCTs(2,8). The consensus content included:

• name of the drug and its purpose

• importance

• dosage regime

• duration of therapy

• administration

• potential interactions

• precautions, side effects and contraindications

The inclusion of precautions, side effects and contraindications had to be balanced

against the importance of the medication(10). Written information to back up verbal

information was recommended but it was less useful on its own(8,10).

The evidence for the efficacy of counselling was confused by the inclusion of

counselling in complex interventions, and diluted by the the variability of

interventions and outcome measures. Five reviews found good evidence that

pharmacist intervention improved outcomes(1,2,7,8,10), though the counselling was

often part of a multi-part or extended intervention. One review found that counselling

was shown to be effective for improving health related outcomes, either objective

(e.g., BP, lipid profile, asthmatic crisis) or subjective (e.g., QOL, satisfaction with

service)(10). Pharmacist-led interventions, including counselling and education,

appeared to be most beneficial in terms of adherence though the results were

variable between individual studies(1) . Four community-based studies using

education failed to reduce hospital admissions(12); again, no details were given on

the nature of the interventions.


[14]

Two studies found weak evidence that counselling was effective(7,11). It was reported

that pharmacist interventions improved most clinical outcomes, but the

improvements were not always statistically significant(7). Ten out of 19 studies in one

review, with education by pharmacists as an intervention, showed significant

improvement in adherence but the intervention went beyond counselling at the point

of dispensing, including education meetings, home visits, and telephone follow-up(11).

Little evidence of enhanced adherence or improved clinical outcomes, irrespective of

intervention method or duration, was found in a review that assessed the 17 RCTs

with the lowest risk of bias (of 182 identified by the search strategy)(6). Another

review noted that pharmacist interventions did not reduce unplanned hospital

admissions(12).

Pharmacist-led interventions had some effect but general education did not(11) and it

was reported that increased patient knowledge did not translate into improved

outcomes(5). Ongoing, tailored interventions were more effective than brief

interventions(11) but these often went beyond counselling at the point of dispensing.

The experience levels of the pharmacist were identified as being important, with less

experienced staff hampering educational interventions(1).

What are the pharmacist’s experience of patient counselling?

There was little systematic evidence on the pharmacist’s experience of patient

counselling. One review assessed the effects of of interventions to improve

adherence in elderly patients prescribed multiple medications(3). Two others included

surveys of pharmacy practice. They investigated community/outpatient pharmacists,

physicians, pharmacy students and high-risk patients(9); and counseling rates and/or

types of information provided for prescription medicines in community pharmacies(10).

It was reported that pharmacists attached more importance to counselling patients

with new medications as they assumed patients would be less knowledgeable about

new prescriptions, and also to conditions that the pharmacists perceived to be more

serious(10).

Community pharmacists were reported as having difficulties practising

pharmaceutical care even with support. Restructuring of community pharmacists’

work practices may be required, for example, increasing the use of pharmacy

technicians or auto-dispensing to free up pharmacists for this type of role(3,9).

In the USA, it was reported that pharmacists found it professionally rewarding to

provide Medication Therapy Management services, which include patient counselling

but also much more extensive interventions. Pharmacists claimed to have adequate

clinical knowledge and experience to provide MTM services(9).


[15]

What skills and training do pharmacists need?

There was no systematic evidence on the skills and training pharmacists need to

conduct patient counselling.

The need for additional training for pharmacists implementing pharmaceutical care

was highlighted in one review but no details of the nature of the training were

given(3).

What are the patients’ experiences of counselling?

There was limited systematic evidence on the patient’s experience of patient

counselling. Two reviews included surveys of pharmacy practice. They investigated

community/outpatient pharmacists, physicians, pharmacy students and high-risk

patients(9); and counseling rates and/or types of information provided for prescription

medicines in community pharmacies(10). Another included a broad range of study

designs exploring and assessing adherence with medication in older people(3).

Giving information to patients increased their awareness of the importance of the

medication. Patients wanted to know about side effects and this was in contrast to

what pharmacists expected(10). The barriers to communication need to be

considered(1), with elderly patients in particular reporting poor communication from

pharmacists(3).

Patients who had taken part in the more extensive Medication Therapy Management

programmes in the USA preferred them to be delivered by pharmacists rather than

doctors and the majority felt more knowledgeable about their medications and were

satisfied with the program(9). One reported concern was the possibility of getting

recommendations from the pharmacist that went against their doctor’s care plan(9).

Conflicting information from prescribers and pharmacists was given as one of the

reasons for medication non-adherence in elderly patients(3) .


[16]

Evidence Gaps

The topics noted below have been specifically suggested by the authors of the

included reviews, or are parts of this review question for which evidence is lacking.

• Specific study of pharmacist counselling delivered at the site of medication

dispensing(2)

• Skills and training required by pharmicists to conduct medication counselling

• Relationship between pharmacist and prescibers(3)

• Consistency of advice provided by various health professionals(3)

• Cost-effectiveness of counselling interventions(8,9)

There was a clear consensus amongst the majority of the review authors that this

was an area in need of further and better research, particularly in the light of the

upcoming changes in pharmacists' practice and service provision.


[17]

References

(1) Banning M. A review of interventions used to improve adherence to medication in

older people. Int J Nurs Stud 2009 Nov; 46(11):1505-1515.

(2) Cutrona SL, Choudhry NK, Fischer MA, Servi A, Liberman JN, Brennan TA, et al.

Modes of delivery for interventions to improve cardiovascular medication adherence.

Am J Manag Care 2010; 16(12):929-942.

(3) George J, Elliott RA, Stewart DC. A systematic review of interventions to improve

medication taking in elderly patients prescribed multiple medications. Drugs Aging

2008; 25(4):307-324.

(4) Higgins N, Regan C. A systematic review of the effectiveness of interventions to

help older people adhere to medication regimes. Age Ageing 2004 May; 33(3):224-

229.

(5) Holland R, Desborough J, Goodyer L, Hall S, Wright D, Loke YK. Does

pharmacist-led medication review help to reduce hospital admissions and deaths in

older people? A systematic review and meta-analysis. Br J Clin Pharmacol 2008

Mar; 65(3):303-316.

(6) Nieuwlaat R, Wilczynski N, Navarro T, Hobson N, Jeffery R, Keepanasseril A, et

al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev

2014 Nov 20;11:CD000011. doi:CD000011.

(7) Nkansah N, Mostovetsky O, Yu C, Chheng T, Beney J, Bond CM, et al. Effect of

outpatient pharmacists' non-dispensing roles on patient outcomes and prescribing

patterns. Cochrane Database of Systematic Reviews 2010 6: (7)-2010.

(8) Okumura LM, Rotta I, Correr CJ. Assessment of pharmacist-led patient

counseling in randomized controlled trials: a systematic review. Int J Clin Pharm

2014 Oct; 36(5):882-891.

(9) Oladapo AO, Rascati KL. Review of survey articles regarding medication therapy

management (MTM) services/programs in the United States. J Pharm Pract 2012

Aug; 25(4):457-470.

(10) Puspitasari HP, Aslani P, Krass I. A review of counseling practices on

prescription medicines in community pharmacies. Research In Social &

Administrative Pharmacy 2009 Sep; 5(3):197-210.


[18]

(11) Schlenk EA, Bernardo LM, Organist LA, Klem ML, Engberg S. Optimizing

Medication Adherence in Older Patients: A Systematic Review. J Clin Outcomes

Manag 2008 Dec 1; 15(12):595-606.

(12) Thomas R, Huntley AL, Mann M, Huws D, Elwyn G, Paranjothy S, et al.

Pharmacist-led interventions to reduce unplanned admissions for older people: a

systematic review and meta-analysis of randomised controlled trials. Age Ageing

2014 Mar; 43(2):174-187.


[19]

Acknowledgements

We would like to thank:

Professor Sandy Oliver, Professor of Public Policy at the Social Science Research

Unit and EPPI-Centre, University College London Institute of Education, for her

advice and comments on the review process and final report.

Jeff Brunton, Research Officer, at the Social Science Research Unit and EPPI-

Centre, University College London Institute of Education, for training and ongoing

support with EPPI-Reviewer 4 software.

Suggested citation for this evidence summary:

Broadfoot, P., MacLeod, K., Manson, P., and O’Brien, S. 2015. Patient counselling

for prescribed medication. Unpublished review: NHS Grampian, Scotland.

Last updated: May 2015

For further information please contact:

Paul Manson, Liaison/Clinical Librarian, NHS Grampian, Aberdeen.

Telephone: 01224 437873

E-mail: [email protected]


[20]

Appendix A: Search Strategies

Searches run on 28 January 2015

Medline

1 exp Community Pharmacy Services/ 2926

2 exp Pharmacies/ 3989

3 exp Pharmacists/ 11085

4 1 or 2 or 3 15934

5 exp Counselling/ 33591

6 exp Patient Education as Topic/ 71035

7 exp Drug Information Services/ 10559

8 exp Consumer Health Information/ 3718

9 exp Medication Therapy Management/ 742

10 5 or 6 or 7 or 8 or 9 115109

11 exp Prescription Drugs/ 3131

12 exp Drug Prescriptions/ 24672

13 11 or 12 27517

14 4 and 10 and 13 272

15 limit 14 to (english language and yr="2004 -Current" and (meta

analysis or systematic reviews))

8

16 ("systematic review" or "meta-analysis").ti,ab. 81008

17 14 and 16 3

18 15 or 17 8


[21]

Embase

1 exp pharmacy/ 56063

2 exp pharmacist/ 50038

3 1 or 2 89699

4 exp counselling/ 112257

5 exp patient education/ 88087

6 exp drug information/ 20823

7 exp consumer health information/ 2366

8 exp medication therapy management/ 3589

9 4 or 5 or 6 or 7 or 8 217924

10 exp prescription drug/ 4148

11 exp prescription/ 117540

12 10 or 11 120382

13 3 and 9 and 12 2883

14 limit 13 to (english language and (meta analysis or "systematic

review") and yr="2004 -Current")

27

15 ("systematic review" or "meta-analysis").ti,ab. 118854

16 13 and 15 24

17 14 or 16 34


[22]

Cochrane Library

1 exp Community Pharmacy Services/ 208

2 exp Pharmacies/ 0

3 exp Pharmacists/ 443

4 1 or 2 or 3 569

5 exp Counselling/ 3356

6 exp Patient Education as Topic/ 6619

7 exp Drug Information Services/ 189

8 exp Consumer Health Information/ 176

9 exp Medication Therapy Management/ 49

10 5 or 6 or 7 or 8 or 9 9755

11 exp Prescription Drugs/ 87

12 exp Drug Prescriptions 625

13 11 or 12 707

14 4 and 10 and 13 11

15 Limit to SR 1


[23]

CINAHL

S1 (MH "Pharmacy, Retail") 3,837

S2 (MH "Pharmacists") 8,427

S3 S1 OR S2 11,018

S4 (MH "Counselling+") 23,172

S5 (MH "Patient Education+") 57,512

S6 (MH "Drug Information Services+") 813

S7 (MH "Consumer Health Information") 9,130

S8 S4 OR S5 OR S6 OR S7 87,854

S9 (MH "Drugs, Prescription") 13,214

S10 (MH "Prescriptions, Drug") 6,007

S11 S9 OR S10 18,909

S12 S3 AND S8 AND S11 118

S13 Limit 12 to 2004-2015 107

S14 (MH "Meta Analysis") 2004-2015 17,934

S15 (MH "Systematic Review") 2004-2015 26,845

S16 S14 OR S15 38,279

S17 TX "systematic review" OR TX "meta-analysis" 122,408

S18 S16 OR S17 122,408

S19 S13 AND S18 3

Epistemonikos

pharm* AND prescri* AND (counsel* or information or interview or educat* or knowledge or communicat* or interact* or instruct*)

799

Limit to 2004-2015, systematic reviews 116


[24]

Appendix B: Details of included studies

Banning (2009)

Title A review of interventions used to improve adherence to medication in older people (Banning, 2009)

What the authors looked for What the authors found

Date of search(for reviews) : 1996 – 2008 Number of studies: 20 Included RCTs, meta-analyses, surveys and literature reviews

Population Participants over 65 that were not taking antipsychotic medication at time of study and were without history of psychotic or personality disorders

Intervention Medication adherence using four approaches to intervention: Behavioural (Drug compliance aids, blister packaging, drug calendars, reminder charts, pill boxes, refill containers) Information giving / educational (Individual and group teaching and discussions, medication cards and charts.) Health professional involvement (Domiciliary visits, brown bag reviews, patient education programmes, mediation review, drug checkups) Health related outcomes (Blood pressure, cholesterol and peak flow monitoring serum and urinary drug levels)

.

Comparison Non-adherence


[25]

Outcomes Increased medication adherence Behavioural – increased adherence poorly illustrated with intervention Information giving / educational – no individual intervention was thought to be superior, though complex interventions are more efficient and productive Health professional involvement – pharmacy involvement show to be beneficial, though not all pharmacist-led interventions were beneficial. Health related outcomes – low quality evidence found regarding the measurement of this approach is measured.

Setting Various – distinction not made between intervention in hospital or community setting

Country Not Specified

Review quality (where appropriate)

Tick one of these statements: This was a Cochrane review published in the Cochrane Library ADD URL This was a Campbell review published in the Campbell Library ADD URL This was a review published by [ADD name], recognised for employing accepted standards for systematic reviewing This review has an AMSTAR score of [ADD score]. AMSTAR, A MeaSurement Tool to Assess Reviews, provides an overall quality rating on a scale of 0 to 11, where 11 represents a review of the highest quality. Categories of quality were determined, as follows: low (score 0 to 3), medium (score 4 to 7), and high (score 8 to 11). This review has been recognised as reliable in Evidence-informed guidelines (eg by SIGN, NICE) (give details) X This review has clear inclusion criteria (as in the table above); searched at least two relevant databases; and appraised the quality of included studies. This review does not meet any of the criteria given above


[26]

Review comments on outcomes

1 No direct comment included regarding the patient experience of counselling. Comment made regarding the consideration of barriers to communication.

2 No comment on the pharmacist’s experience of counselling.

3 No comment on the skills and training required by pharmacists for effective counselling.

4 Pharmacist-led interventions, including counselling and education, appeared to be most beneficial in terms of adherence though the results were variable between individual studies. Simplifying medicine dosing regimens was effective. General educational interventions were not beneficial. Pharmacists who lacked clinical experience impeded the success of educational interventions.

General Pharmacist-driven interventions are resource intensive.


[27]

Choudhry (2010)

Title Modes of Delivery for Interventions to Improve Cardiovascular Medication Adherence (Choudhry, 2010)


Date of search(for reviews) : 1966 - 2006

Number of studies: 51

Population Patients being treated for cardiovascular disease or diabetes

Intervention Medication adherence including in-person patient intervention .

Comparison Non-adherence to medication

Outcomes Increased medication adherence

Of 6 interventions that were conducted in pharmacies, all administered by pharmacists. All but 1 study in this group showed success at improving adherence. The group of interventions carried out in the clinic by pharmacists, only 3 out of 8 were effective.

Setting Various (no distinction made between hospital and community settings in the search strategy)

Country Not specified


Tick one of these statements: This was a Cochrane review published in the Cochrane Library ADD URL This was a Campbell review published in the Campbell Library ADD URL This was a review published by [ADD name], recognised for employing accepted standards for systematic reviewing This review has an AMSTAR score of [ADD score]. AMSTAR, A MeaSurement Tool to Assess Reviews, provides an overall quality rating on a scale of 0 to 11, where 11 represents a review of the highest quality. Categories of


[28]

quality were determined, as follows: low (score 0 to 3), medium (score 4 to 7), and high (score 8 to 11). This review has been recognised as reliable in Evidence-informed guidelines (eg by SIGN, NICE) (give details) X This review has clear inclusion criteria (as in the table above); searched at least two relevant databases; and appraised the quality of included studies. This review does not meet any of the criteria given above


1 No direct comment included regarding the patient experience of counselling. Recommendations for future research focus includes note regarding the need for additional research into in-person pharmacist counsel delivered at the site of medication dispensing.



4 Review found a high success rate for pharmacist-led personal interventions; 5 of 6 studies showed improved adherence. Interventions based in a pharmacy were more effective than those in a clinic. Suggested content for counselling interview gathered from one study in Northern Ireland.

General Review of cardiovascular medication only. Pharmacist counselling delivered at the site of medication dispensing (so that arriving for an appointment to discuss adherence can be combined with retrieving the medication) is an area recommended for further research.


[29]

George (2008)

Title A Systematic Review of Interventions to Improve Medication Taking in Elderly Patients Prescribed Multiple Medications (George, 2008)


Date of search(for reviews) : Various depending on database - 2006 Number of studies: 8

Population Community-living elderly patients prescribed at least three, or a mean/median of four or more, long-term medications.

Intervention Medication adherence, in particular patient education in combination with behavioural strategies and/ or provider-focused strategies

.

Comparison Non-adherence to medication

Outcomes Increased medication adherence measured using self-reported medication utilization, the Morisky scale, refill data, prescription claims data and pill count.

Hospital pharmacists delivered the intervention in three studiescommunity or primary care pharmacists in four studies and in one study the intervention was shared between hospital and community pharmacists.

Setting Various (distinction not made between community and hospital setting in search strategy)



Tick one of these statements: This was a Cochrane review published in the Cochrane Library ADD URL This was a Campbell review published in the Campbell Library ADD URL This was a review published by [ADD name], recognised for employing accepted standards for systematic reviewing


[30]

This review has an AMSTAR score of [ADD score]. AMSTAR, A MeaSurement Tool to Assess Reviews, provides an overall quality rating on a scale of 0 to 11, where 11 represents a review of the highest quality. Categories of quality were determined, as follows: low (score 0 to 3), medium (score 4 to 7), and high (score 8 to 11). This review has been recognised as reliable in Evidence-informed guidelines (eg by SIGN, NICE) (give details) X This review has clear inclusion criteria (as in the table above); searched at least two relevant databases; and appraised the quality of included studies. This review does not meet any of the criteria given above


1 The authors note that elderly patients have reported poor communication and conflicting information from prescribers and pharmacists as one of the reasons for medication non-adherence. The authors go on to say most adherence studies provide no insight into the quality of this relationship or the consistency of advice provided to patients by the various professionals involved.


3 The need for additional training for pharmacists implementing pharmaceutical care was highlighted but no details of the required training were given.

4 The four individual studies that demonstrated a significant difference in adherence rates used individualized patient education.

General Review was specifically concerned with older people who had multiple morbidities and were on at least 3 long-term medications. All individual studies included education in addition to behavioural interventions. The review could not draw firm conclusions due to variability in the studies. It was noted that community pharmacists had difficulties practising pharmaceutical care even with support. Restructuring of community pharmacists’ work practices may be required, for example, increasing the use of pharmacy technicians or auto-dispensing to free up pharmacists for this type of role.


[31]

Higgins (2004)

Title A systematic review of the effectiveness of interventions to help older people adhere to medication regimes (Higgins, 2004)


Date of search(for reviews) : Various depending on database - 2002


Population Patients 65 and over

Intervention Medication adherence [divided into two categories – external cognitive supports and education strategies]

.

Comparison Non-adherence

Outcomes Increased medication adherence With regard to adherence “Single discrete interventions were disappointing and positive effects were only found with combinations of approaches.” Concluded that there was not any strong evidence at the time to support the use of any one intervention measure to improve adherence.

Setting Various – distinction not made between intervention in hospital or community setting in the search strategy



Tick one of these statements: This was a Cochrane review published in the Cochrane Library ADD URL This was a Campbell review published in the Campbell Library ADD URL This was a review published by [ADD name], recognised for employing accepted standards for systematic


[32]

reviewing This review has an AMSTAR score of [ADD score]. AMSTAR, A MeaSurement Tool to Assess Reviews, provides an overall quality rating on a scale of 0 to 11, where 11 represents a review of the highest quality. Categories of quality were determined, as follows: low (score 0 to 3), medium (score 4 to 7), and high (score 8 to 11). This review has been recognised as reliable in Evidence-informed guidelines (eg by SIGN, NICE) (give details) X This review has clear inclusion criteria (as in the table above); searched at least two relevant databases; and appraised the quality of included studies. This review does not meet any of the criteria given above


1 No direct comment included regarding the patient experience of counselling. Counselling mentioned in passing as an intervention, and delivered by pharmacists in one included study.



4 Education strategies included face-to-face, telephone and written, and had mixed success. Statistically significant results had little clinical effect.

General Only one study took place in primary care, all others were hospital-based. Mixed interventions were most effective.


[33]

Holland (2007)

Title Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis (Holland, 2007)


Date of search(for reviews) : Various depending on database - 2005


Population Mainly included older people (mean age of subjects > 60 years); and encompassed patients with a range of diseases (more than one diagnostic category)

Intervention Pharmacist-led review of patient’s medication to reduce hospital admission or mortality

Comparison Usual care

Outcomes Proportion of patients with one or more hospital emergency admission. Secondary outcomes were all-cause mortality and mean drugs prescribed

The review did not find any clear effect on hospital admission or mortality as a result of pharmacist-led medication review. The authors state that these interventions may improve drug knowledge and drug adherence.

Setting Studies in clinical, hospital, community and patients home settings were included



Tick one of these statements: This was a Cochrane review published in the Cochrane Library ADD URL This was a Campbell review published in the Campbell Library ADD URL This was a review published by [ADD name], recognised for employing accepted standards for systematic


[34]

reviewing This review has an AMSTAR score of [ADD score]. AMSTAR, A MeaSurement Tool to Assess Reviews, provides an overall quality rating on a scale of 0 to 11, where 11 represents a review of the highest quality. Categories of quality were determined, as follows: low (score 0 to 3), medium (score 4 to 7), and high (score 8 to 11). This review has been recognised as reliable in Evidence-informed guidelines (eg by SIGN, NICE) (give details) X This review has clear inclusion criteria (as in the table above); searched at least two relevant databases; and appraised the quality of included studies. This review does not meet any of the criteria given above


1 No comment on the patient experience of counselling.



4 The review found that increased knowledge only translated to a positive effect in half the studies, but the authors caution that this was not a focus for the review so it may not be representative.

General The review did not evaluate interventions which were designed solely to improve knowledge or medication adherence.


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Nieuwlaat (2014)

Title Interventions for enhancing medication adherence (Nieuwlaat 2014) What the authors looked for What the authors found Date of search(for reviews) : 2008 – Jan 2013 (update to search of

1993 - 2007 for 2008 review) Number of studies: 182 (109 new + 73 from 2008 review - 5 from 2008 review excl in 2013 update)

Population Patients prescribed drugs for medical or psychiatric disorders excl addiction. All health professionals (not necessarily including pharmacists)

Intervention Any intervention intended to affect adherence with prescribed, self-administered medications.

.

Comparison No intervention/ care as usual

Outcomes Assessment of effects of interventions to enhance adherence to prescribed medicine, including clinical as well as adherence outcomes.

Little evidence of enhanced adherence or improved clinical outcomes irrespective of intervention method or duration. Only 5 of the 17 highest quality reviews discussed at length provided convincing evidence of improvements.

Setting Various – mostly not pharmacies Of the 17 included RCTs with the lowest risk of bias (main focus of authors), 1 relates solely to hospital pharmacy, I describes an initial hosp pharmacist intervention with community pharmacy follow up, 2 focus specifically on community pharmacist intervention.

Country Worldwide, not specifically Westernised countries. Review quality (where appropriate)

X Tick one of these statements: This was a Cochrane review published in the Cochrane Library http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000011.pub4/pdf


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This was a Campbell review published in the Campbell Library ADD URL This was a review published by [ADD name], recognised for employing accepted standards for systematic reviewing This review has an AMSTAR score of [ADD score]. AMSTAR, A MeaSurement Tool to Assess Reviews, provides an overall quality rating on a scale of 0 to 11, where 11 represents a review of the highest quality. Categories of quality were determined, as follows: low (score 0 to 3), medium (score 4 to 7), and high (score 8 to 11). This review has been recognised as reliable in Evidence-informed guidelines (eg by SIGN, NICE) (give details) This review has clear inclusion criteria (as in the table above); searched at least two relevant databases; and appraised the quality of included studies. This review does not meet any of the criteria given above

Review comments on outcomes 1 No direct comment included regarding the patient experience of counselling.

2 Mention of possibility of usefulness of ‘expanded role’ for pharmacists/AHPs rather than training needs 3 Mention of specific reimbursement for pharmacists under research funding; questions whether pharmacists would

be willing to dedicate time and resources without it. 4 Complex interventions including counselling provided by allied health professionals including pharmacists were

effective but the efficacy of particular components couldn’t be determined. General 182 studies identified in searches but the authors limit the review to a narrative analysis of the 17 RCTs deemed

to be at the least risk of bias. Includes short section on ‘Promising interventions not included in our review’ e.g., development of poly-pills and change to once or twice a day regimes Authors conclude that adherence research to date lags behind rapid technological developments Authors point out that most interventions discussed in RCTs in comparison to ‘usual care’ are complex, making it difficult to tease out the individual elements that might be successful Discusses difficulty of accurate adherence measurement, and concludes that pharmacy refill records are the method least at risk of bias. The authors suggest, in their discussion of interventions, that pharmacists and other AHPs might be more successful counsellors than physicians who have ‘limited time, and sometimes skills, to counsel patients on medication adherence’


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Nkansah (2010)

Title Effect of outpatient pharmacists' non-dispensing roles on patient outcomes and prescribing patterns (Nkansah 2010)

What the authors looked for What the authors found Date of search(for reviews) : 1966 – March 2008

Number of studies: 43 (36 targeting patients, 7 targeting health professionals)

Population Pharmacists delivering services in an outpatient setting incl community and outpatient facilities attached to hospitals

Intervention Pharmacists’ non-dispensing roles in patient care . Comparison Similar services for patients delivered by other health professionals

(OHPs) No comparable service for patients Pharmacist services targeted at OHPs Pharmacist services targeted at OHPs v no comparable service

Outcomes Impact of pharmacist-provided patient care on health-related outcomes Relevant patient outcomes included changes in eg blood pressure and quality of life outcomes

Data included in the review “supported the roles of pharmacists in patient counseling, therapeutic management and health education to improve patient care and clinical outcomes”. 3 studies showed measurable improvements in quality of life; 29 studies reported on clinical and humanistic outcomes – “Pharmacist interventions resulted in improvement in most clinical outcomes, although these improvements were not always statistically significant. ”

Setting Community and ambulatory care

Country World-wide, Western


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Tick one of these statements: X This was a Cochrane review published in the Cochrane Library http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000336.pub2/pdf/standard This was a Campbell review published in the Campbell Library ADD URL This was a review published by [ADD name], recognised for employing accepted standards for systematic reviewing This review has an AMSTAR score of [ADD score]. AMSTAR, A MeaSurement Tool to Assess Reviews, provides an overall quality rating on a scale of 0 to 11, where 11 represents a review of the highest quality. Categories of quality were determined, as follows: low (score 0 to 3), medium (score 4 to 7), and high (score 8 to 11). This review has been recognised as reliable in Evidence-informed guidelines (eg by SIGN, NICE) (give details) This review has clear inclusion criteria (as in the table above); searched at least two relevant databases; and appraised the quality of included studies. This review does not meet any of the criteria given above

Review comments on outcomes 1 No direct comment included regarding the patient experience of counselling.

2 Pharmacist experience not discussed 3 No discussion of training needs 4 8 of 36 studies were primarily concerned with patient education; the others had complex interventions that

included education or counselling. Pharmacist-led interventions were beneficial in improving patient outcomes although effect sizes were not always substantial or statistically significant. The review concludes that the evidence supports the provision of patient counselling by pharmacists.

General The review only considered studies with objective outcome measurements (e.g., cholesterol levels, BP, hospital admissions) not subjective outcomes (e.g., self-reported symptoms, knowledge, patient satisfaction) Heterogeneity of measurement of outcomes, comparison groups etc cited as a difficulty in extrapolating pooled analysis from included reviews, and also a barrier to summarizing overall benefits. Detailed discussion of studies (29) re pharmacists targeting patients v no comparable service (p9) “One study examined anticoagulation, diabetes, dyslipidemia, and hypertension control in patients with a high risk of medication related problems and found a significant increase in the proportion of patients at goal for these conditions as a result of the pharmacist intervention [Taylor 2003]” See also Best Practice above


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Okumura (2014)

Title Assessment of pharmacist-led patient counseling in randomized controlled trials: a systematic review. What the authors looked for What the authors found Date of search(for reviews) : 1990 -2013

Number of studies: 753 studies: 101 included

Population Adult patients. Clinical and community pharmacists.

Intervention ‘Positive health related outcomes’ in five areas: Clinical outcomes: in a wide variety of diseases and conditions eg high blood pressure, asthma, acute coronary syndromes, depression and schizophrenia Humanistic outcomes: quality of life, patients’ satisfaction with service Economic outcomes: cost effectiveness and cost savings associated with drug therapies Lifestyle changes: more nutritive/less calorific diet, smoking cessation, more physical activity Drug/disease knowledge: improved drug self-monitoring and drug use

.

Comparison None of the above achieved

Outcomes Increased positive health outcomes through pharmacist interventions

Clinical outcomes – states ‘proven effectiveness in promoting and preventing drug therapy related morbidity’ (but the authors don’t specify where this evidence is to be found) although ‘none demonstrated reduced mortality’ Humanistic outcomes – states commonly reported variable as a demonstration of effectiveness Economic outcomes - in only 4% of


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included RCTs. States a need to align the costs involved in pharmacy services with other health services/ outcomes Lifestyle changes – mentioned as a concept, statistically highly reported in RCTs Drug/disease knowledge – commonly reported variable as an indication of effectiveness of pharmacist intervention

Setting Both clinical and community pharmacies Emphasis on hospital based as found more evidence there – ‘community pharmacy was not often reported as a setting to conduct a clinical service’ and in these studies was used ‘mainly to detect adherence problems’

Country Worldwide, including non-Westernised countries Review quality (where appropriate)



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Review comments on outcomes 1 No direct comment included regarding the patient experience of counselling. 2 No discussion of pharmacist experience

3 No discussion of training needs 4 Medication counselling was shown to be effective for improving health related outcomes, either objective (e.g.,

BP, lipid profile, asthmatic crisis) or subjective (QOL, satisfaction with service). Written information is most useful as a back-up to verbal information. Recommended content included the purpose of the medication, its importance, precautions (adverse reactions or interactions), dosage regime, and administration. Less often it included missed dosages and storage.

General Review explicitly set out to identify the structure, processes and technical content of pharmacist counselling. Most counselling took place in clinics or discharge from hospital rather than when dispensing medications or in a community pharmacy (only 18/101 studies). Content & format of counselling was not well described in constituent RCTs. Most of the discussion stops at statistical analysis of the included results for the 5 outcomes detailed above. The effectiveness of the various interventions in achieving any of the outcomes is not discussed. The authors point out the limitations of research so far, and their own review. Specifically The need to improve the quality of pharmacist-led RCTs by reporting verbal and written counseling and describing outputs, withdrawals and randomization. The fact that it is difficult to blind education or counselling research Few included studies described in detail how medication counseling was performed, so that the manuscript was limited to descriptive analysis rather than innovation in pharmacist interventions.


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Oladapo (2012)

Title Review of survey articles regarding medication therapy management (MTM) services/programs in the United States.

What the authors looked for What the authors found Date of search(for reviews) :

< Oct 2011 (surveys included were conducted between 2004-2009) Number of studies: 405 studies, 32 included Review of surveys, not RCTs

Population Surveys conducted on Community/Outpatient Pharmacists, Physicians, Pharmacy Students and high-risk Patients (Medicare Part D beneficiaries with multiple chronic illnesses, who are on multiple covered Part D medications and whose medication costs could likely exceed a predetermined threshold level)

Intervention Provision of Medication Therapy Management (MTM) services to high-risk patients. 5 core elements required of any MTM program - medication therapy review, a personal medication record, a medication action plan, intervention and referral, and documentation and follow-up. MTM services targeted at, Improving patient’s drug use Clinical outcomes Quality of life Reduced risk of adverse events and reduced overall health care costs Surveys covered issues centered around implementation, enrollment, delivery, compensation, attitudes, perception, satisfaction, willingness to pay and training needs/skills & knowledge.


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Outcomes Due to the limitations of the study type and the fact that there have been limited published studies on this subject, the authors state that ‘this summary can provide a reference for future research work that seeks to measure improvements in MTM services provided’ and as such it does not seek to provide conclusions on each area of intervention. The authors state that ‘the majority of pharmacists surveyed stated an overall willingness, intention or interest to provide MTM/direct patient care services. Most pharmacists claimed they have adequate clinical knowledge, experience, and access to information required’ for MTM services. ‘Pharmacists were also of the opinion that MTM services would be best provided by them...and would improve medication usage, therapeutic response/clinical outcome, quality of care/quality of life for the patient, as well as [provide] satisfaction for both the patient and the provider.’ Willingness to pay was found to be associated with insurance status and presence of certain chronic conditions.


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Challenges include reimbursement issues for pharmacists, variability of program content due to different health plans, administrative burdens and poor interprofessional collaboration. Note - Lack of standardization in the design and delivery of these services has the potential to affect their quality and impact.

Setting Various Of 32 articles, 17 surveyed community/outpatient pharmacists, 3 surveyed pharmacy students, 4 surveyed physicians and 8 surveyed patients.

Country USA



Review comments on outcomes 1 Patient experience of MTM

Although those surveyed agreed MTM services should be provided by pharmacists, many were not aware of its availability nor did they see the need for such services. However, patients were ‘reported to be more favourable


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toward pharmacists’ provision of MTM services’ as opposed to physician provision and the majority of surveyed MTM patients felt more knowledgeable about their medications and were satisfied with the program. The authors reported patients’ ‘fear of obtaining recommendations which may be contrary to their physician’s plan of care’ and ‘Patients suggested that alternative ways need to be explored in describing and marketing MTM services for it to be appealing to them.’

2 Pharmacist experience of MTM ‘Despite the identified barriers to the provision of MTM services, pharmacists reportedly found it professionally rewarding to provide these services. Pharmacists claimed to have adequate clinical knowledge, experience, and access to information required to provide MTM services.’ Barriers include – lack of time, high workload, shortage of staff, reimbursement issues, lack of access to patients’ records, patients’ lack of interest, lack of collaborative practice agreement with physicians and non-uniformity in program design and delivery.

3 Skills or training The authors state that pharmacists need to be able to access training materials or take classes on providing MTM services as the service is crucial to the future of pharmacy. Pharmacists appear more likely to provide MTM services if they possess a PharmD degree and as such the authors suggest that ‘courses on MTM services/patient care need to be fully integrated into the PharmD curriculum and residency programs’ along with early introduction and continuous reinforcement of the concept. In addition, pharmacists expressed interest in receiving additional training, especially in areas pertaining to billing and documentation.

4 No discussion on format, content or efficacy of patient counseling

General This article aims to provide a summary of published survey articles regarding the provision of MTM services in the USA. Note – The authors state that MTM differs from patient counseling because it is delivered independent of dispensing and involves collaboration with patients and providers. The authors report poor interprofessional collaboration due to unfavourable physician perception regarding the ability of pharmacists to provide MTM services. Efforts need to be made towards educating physicians on the value of MTM and the role of pharmacists as complementary (and not competitive) in improving patients’ health outcome. Physicians of the opinion that the most important benefit of MTM services lies in having a complete patient medication list.


[46]

Puspitasari (2009)

Title A review of counseling practices on prescription medicines in community pharmacies.


Date of search(for reviews) : 1993-2007

Number of studies: 40 Observational studies and surveys, not RCTs.

Population Adults attending a community pharmacy for prescription medicine

Intervention Patient counseling .


Outcomes Lower counseling rates were found from the consumer and observational studies compared with pharmacist and simulated patient studies. Higher rates of counseling were found with new compared with regular prescriptions. Information on directions for use, dose, medicine name and indications was more frequently given than information on side effects, precautions, interactions, contraindications, and storage. Evidence suggests that through patient counseling, pharmacists may identify and resolve drug-related problems, empower patients to adopt positive self-management behavior, increase patient satisfaction with pharmacy care, and optimize patient quality of care.


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Setting Community Pharmacy - International

Country Not restricted by country but limited to articles in English




1 Information from pharmacists increased patients’ awareness of the importance of medications. Patients specifically wanted information on potential side effects. There is evidence to suggest that patients do not remember everything they are told in consultations and so they report lower counseling rates.

2 One study found that pharmacists judged the importance of counseling depending on patients’ familiarity with the medication, where patients collecting new medicines are assumed to be less knowledgeable, and also on pharmacists’ perceived seriousness of patients’ conditions.

3 Skills or training – no discussion

4 Counselling should take place in a private & comfortable situation; it should take account of patient’s understanding, feelings, and cognitive abilities. Written information is essential when verbal information is not considered sufficient. The content of counselling should include the name and description of the medicine, indications, route of administration, dosage, directions for use, duration of therapy, special directions, precautions, side effects, and contraindications. Pharmacists often limited information on side effects as they thought this might lead to reduced compliance, but patients felt that more information showed them the importance of their


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medication. Counselling has been shown to be effective in identifying drug-related problems, encouraging self-management, increasing satisfaction with pharmacy care, and improving quality of care.

General Review specifically set out to quantify counselling rates and the types of information provided in counselling. Counselling rates varied from 8-80%, depending on the research method. Patients collecting new prescriptions were more frequently counselled than patients collecting repeat prescriptions. The authors acknowledge the limitations of finding actual counseling rates due to the differences and limitations of each research method. ‘Rees argues that what pharmacists give is much more than just advice because this process involves empathetic understanding, acceptance, and genuine feelings from pharmacists.’


[49]

Schlenk (2008)

Title Optimizing Medication Adherence in Older Patients: A Systematic Review


Date of search(for reviews) : 2007 Number of studies: 33 (34 papers)

Population > 65 years old

Intervention Education or memory aids .


Outcomes Medication adherence rates

Setting Community

Country Not stated




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4 28 of 33 studies included education as an intervention, not all by pharmacists. In general, education interventions did not consistently improve adherence. Most effective were tailored interventions that included on-going contact. 10 of 19 studies with education by pharmacists as an intervention showed significant improvement in adherence but the intervention went beyond counselling at the point of dispensing, including education meetings, home visits, and telephone follow-up.

General


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Thomas (2014)

Title Pharmacist-led interventions to reduce unplanned admissions for older people: A systematic review

and meta-analysis of randomised controlled trials.


Date of search(for reviews) : 2010 Number of studies: 20

Population > 60 years old

Intervention ‘Pharmacist led’ interventions: medication review, counselling,

home visit, telephone support


Outcomes Unplanned hospital admission

Setting Community (10) and hospital (10)

Country OECD countries

Review

quality

(where

Tick one of these statements:

� This was a Cochrane review published in the Cochrane Library ADD URL

� This was a Campbell review published in the Campbell Library ADD URL X This was a review published by NIHR, recognised for employing accepted standards for systematic


[52]

appropriate) reviewing

� This review has an AMSTAR score of [ADD score]. AMSTAR, A MeaSurement Tool to Assess Reviews, provides an overall quality rating on a scale of 0 to 11, where 11 represents a review of the highest quality. Categories of quality were determined, as follows: low (score 0 to 3), medium (score 4 to 7), and high (score 8 to 11).

� This review has been recognised as reliable in Evidence-informed guidelines (eg by SIGN, NICE) (give details)

� This review has clear inclusion criteria (as in the table above); searched at least two relevant databases; and appraised the quality of included studies.

� This review does not meet any of the criteria given above





4 4 community-based studies using education failed to reduce hospital admissions; no details were given on

the nature of the interventions.

General Only 4 of 10 community-based studies took place in the pharmacy, the others were based in surgeries or

patients’ homes. Pharmacist-led interventions, whether community or hospital based, do not affect

unplanned hospital admissions in older people

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