Research in Social and Administrative Pharmacy xxx (xxxx) xxx

Contents lists available at ScienceDirect

Research in Social and Administrative Pharmacy

journal homepage: www.elsevier.com/locate/rsap

Impact of community-pharmacist-led medication review programmes on

patient outcomes: A systematic review and meta-analysis of randomised
controlled trials
Basmah Al-babtain a, b, *, Ejaz Cheema b, Muhammad Abdul Hadi b
a
Department of Pharmaceutical Practice, College of Pharmacy, Princess Nourah Bint Abdulrahaman University, Riyadh, Saudi Arabia
b
School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The role of pharmacists has evolved over the past few decades from being product-oriented to
Medication review being service-oriented. Community-pharmacist-led medication review programmes have been commissioned in
Community pharmacy different countries under different names. The services provided by general pharmacists can have a positive
Pharmacist
impact on patient health, but the impact of the services offered by community pharmacists is relatively unknown.
Systematic review
meta-Analysis
Objective: To evaluate the effectiveness of community-pharmacist-based medication review programmes among
patients with long-term conditions. Methods: The electronic databases Cochrane Library, MEDLINE and Embase
were searched from their inception until January 2020 for randomised controlled trials (RCTs) published in the
English language assessing the effectiveness of community-pharmacist-led medication review programmes on
patients’ clinical and healthcare utilisation outcomes. Random-effects meta-analysis was used to pool data sta­
tistically, where applicable. The study protocol was published in PROSPERO (ID: CRD42020165693). Results:
Forty-two reports of 40 RCTs were included in the systematic review, and 12 RCTs were included in the meta-
analysis. Compared to the control, a significant improvement was noted in the community-pharmacist-based
medication review group for the following outcomes: blood pressure (BP) in patients with diabetes (mean dif­
ference [MD] in systolic blood pressure [SBP]: 6.82 [95% CI -11.33, − 2.32]; MD in diastolic blood pressure
[DBP]: 2.13 [95% CI -3.35, − 0.92]) and in the hypertension patients (MD in SBP: 6.21 [95% CI -13.26, 0.85]; MD
in DBP: 2.11 [95% CI -6.47, 2.26]), HbA1c in patients with diabetes (MD -0.61; 95% CI -0.96, − 0.25), and total
cholesterol (TC) in patients with hyperlipidaemia (MD -0.18; 95% CI -0.32, − 0.05). Conclusion: Community-
pharmacist-led medication review can improve certain clinical and healthcare utilisation outcomes in patients
with long-term conditions.

Introduction problems and reducing waste”.4 Broadly, the role of pharmacists has
evolved over the past few decades from being product-centred to being
Globally, elderly people with chronic diseases need to take multiple patient-centred.5 Pharmacist-led medication review programmes have a
medications, which can lead to increased risk of drug-induced morbidity potential for improving patients’ health outcomes by identifying and
and increased potential for drug-related problems.1 Accordingly, there is resolving drug-related problems (DRPs) and improving patients’ drug
a major potential for patients to benefit from pharmaceutical care pro­ use. Furthermore, medication reviews can reduce polypharmacy and
vision by pharmacists as many drug-related problems are preventable promote the use of appropriate drug formulations.6–8 Pharmacist-led
with careful medication review.1–3 Medication review has been defined medication reviews also help promote safe medication use and medi­
by the National Institute for Health and Care Excellence as “a structured, cation adherence by establishing effective patient–pharmacist
critical examination of a person’s medicines with the objective of collaboration.6–12
reaching an agreement with the person about treatment, optimising the Pharmacist-led medication review programmes have been commis­
impact of medicines, minimising the number of medication-related sioned in different countries under different names, and their prevalence

* Corresponding author. Department of Pharmaceutical Practice, College of Pharmacy, Princess Nourah Bint Abdulrahaman University, Riyadh, Saudi Arabia.
E-mail address: [email protected] (B. Al-babtain).

https://doi.org/10.1016/j.sapharm.2021.04.022
Received 2 November 2020; Received in revised form 28 February 2021; Accepted 25 April 2021
Available online 29 April 2021
1551-7411/© 2021 Elsevier Inc. All rights reserved.

Please cite this article as: Basmah Al-babtain, Research in Social and Administrative Pharmacy, https://doi.org/10.1016/j.sapharm.2021.04.022
B. Al-babtain et al. Research in Social and Administrative Pharmacy xxx (xxxx) xxx

suggests that many health systems prioritise the value of the services Table 1
they provide. Such services include medication therapy management in The participant/population, intervention, comparator/control, outcome (PICO)
the United States, MedsCheck in Canada, medicines use review (MUR) in framework.
the United Kingdom, medicines therapy assessment (MTA) in New Criteria (PICO) Definition
Zealand, medication management review (MMR) in Jordan, NetCare in Participants/ Patients aged 18 years and above receiving the intervention
Swaziland, and clinical medication review (CMR) in Australia, among population of interest led by a community pharmacist
others.5 Intervention(s) The following operational definition of medication review
Several systematic reviews have evaluated the effectiveness of programme was used:
‘a set of actions undertaken by a pharmacist and structured
medication review programmes and have reported their positive impact
to be delivered directly to the patient either face to face or by
on patient outcomes.13–20 However, previous systematic reviews were telephone in a community pharmacy, consisting of a critical
either focused on a specific disease type13–16 or limited to certain examination of a patient’s medicines with the objective of
countries10,17 or a specific type of medication review.18–20 Furthermore, reaching an agreement with the patient about the treatment
most of such systematic reviews included both RCTs and non-RCTs and to optimise the process of care and the impact of the
medicines, with the aim of improving the patient’s health
also included studies in which intervention was delivered by other outcomes and the value of the healthcare he or she is
healthcare professionals. Therefore, the effectiveness of medication re­ receiving, including the detection and resolution of drug-
view services delivered by pharmacists in community pharmacy settings related problems (DRPs) directly or through referral to a
remains unclear. physician.’
All forms of medication review for checking and optimising
To the best of our knowledge, no study involving both a systematic
the patients’ drug regimens were considered, provided that
review and a meta-analysis has comprehensively evaluated the effec­ the interventions were not limited to simply increasing the
tiveness of community-pharmacist-led medication review programmes patients’ knowledge and/or adherence. The programme
across different countries involving patients with various long-term should define the structure of interventions and should not
conditions. This study involving both a systematic review and a meta- simply provide a one-step intervention delivered by
pharmacists.
analysis aims to fill this gap by focusing specifically on RCTs that
Community-pharmacist-led medication review programmes
evaluated the effectiveness of community-pharmacist-led medication under different names in different countries were
review programmes, and will help policymakers make an informed de­ considered.
cision on how to improve patients’ drug use. Comparator(s)/ ‘No intervention’, ‘usual care’, ‘standard care’, and ‘any
control other intervention delivered by a registered healthcare
professional other than pharmacist’.
Methods Outcomes Clinical and health services utilisation outcomes

This review was conducted as per the guidance of the Preferred

Reporting Items for Systematic Reviews and Met-Analysis (PRISMA).21 pharmacist-led medication review programme delivered in the com­
The study methodology was pre-specified in a protocol that was regis­ munity pharmacy setting on patients’ clinical and healthcare utilisation
tered in the International Prospective Register of Systematic Reviews outcomes were included in this study involving a systematic review and
(PROSPERO) (registration number: CRD42020165693).22 a meta-analysis. The intervention should have been delivered either face
to face or by telephone.
Search strategy
Exclusion criteria
A systematic literature search was performed using three major
electronic health-related databases: Cochrane Library, MEDLINE and We excluded the studies that were published in a language other than
Embase. The search covered the relevant published RCTs that were English as well as editorials, systematic reviews, letters to the editor and
uploaded in such databases from the databases’ inception up to January conference abstracts.
1, 2020. The following search terms were used: “Pharmaceutical care’’,
“Community Pharmacy Services”, “Clinical pharmacy service”, “Medi­ Study selection
cation review”, “Drug review”, “Drug Utilisation Review”, “Medication
Therapy Management”, “Medscheck”, “Home medicines review”, All the search results were exported to a reference manager software
“Medicines use review”, “Medicines therapy assessment”, “Netcare”, (i.e. EndNote©). After deduplication, a two-stage approach was used for
“Drug therapy management”, “Medication management”, “Drug man­ study selection. In the first stage, the study titles and abstracts were
agement”, “Drug regimen review”, “Medication regimen review”, screened, and the study titles that were clearly irrelevant to this study’s
“Pharmacists/Pharmacist and Pharmacies/Pharmacy”. aim were excluded. In the second stage, one author (BA) downloaded
The search terms were combined using Boolean operators. The the full texts of the relevant studies and reviewed these against this
complete search terms for each database are provided in Table S1. Web study’s inclusion/exclusion criteria. Another author (MAH) then
searches (Google Scholar), legislation, government documents, annual checked the results of such review. This was followed by abstract
reports, statistics and dissertations were then examined for additional screening against the eligibility criteria. In case the two authors disagree
relevant literature, followed by citation chaining for both full-text over the eligibility of a particular study, all of us (the study authors: BA,
studies and relevant systematic reviews as a complementary search MAH and EC) resolved the matter through mutual discussion.
activity.
As pre-specified in the protocol, the key theme of this study involving Data extraction
a systematic review and a meta-analysis was the effect of community-
pharmacist-led medication review programmes on patients’ outcomes We collected and tabulated the data from all the included studies
globally. For streams related to interventions, the traditional mnemonics using a standardised form that we adapted from Cochrane Collabora­
for inclusion criteria (PICO) was used (Table 1). tion’s data collection form.23 We piloted the form before the data
extraction process. BA extracted data independently. EC and MH were
Eligibility criteria responsible for verifying the data extraction process. General informa­
tion regarding the characteristics of the studies was extracted, including
Inclusion criteria the names of the authors, the year of publication, the country of origin,
All published RCTs and RCT clusters that assessed the effect of a the study design, the population description and setting, the eligibility

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criteria, the study aim and objectives, the sample size, the number of considered P < 0.05 statistically significant. For the narrative de­
participants in each arm, the mean age, the type of intervention and scriptions and meta-analyses, we grouped the studies based on their
control, the duration of follow-up, the outcomes assessed, the sum­ relevant outcomes. Also, we used subgroup analysis by study population
marised results, the main findings of the study, etc. In the case of a for meta-analysis.
dispute among us (the authors) regarding such information, we dis­ Pooling of data using meta-analysis was performed depending on the
cussed the matter and reached a consensus regarding it. We also con­ clinical homogeneity, and the clinically heterogeneous trials were not
tacted the authors of the selected articles for clarification and/or to combined statistically. A narrative description of the outcomes was
obtain missing data. provided when meta-analysis was not possible.
In the meta-analysis, we pooled the results if data on the same out­
Risk-of-bias assessment comes were available from three or more studies. A random-effects
meta-analysis model (i.e. a model used to combine clinically homolo­
BA independently assessed the risk of bias in each included study gous but statistically heterogeneous trials) was used for conducting
using Cochrane Collaboration’s tool for assessing risk of bias,24 and EC meta-analysis. We ascertained clinical homogeneity on the basis of the
checked it for accuracy. Random sequence generation (selection bias), similarities in the study population, the nature and duration of inter­
allocation concealment (selection bias), blinding of participants and vention and the outcomes assessed. Statistical heterogeneity was
personnel (performance bias), blinding of outcome assessment (detec­ measured on the basis of the I2 statistic, with a less than 25% I2 value
tion bias), incomplete outcome data (attrition bias), selective reporting indicating low heterogeneity, 25–50% indicating moderate heteroge­
(reporting bias) and other sources of bias were used to summarise the neity, and >50% values indicating significant heterogeneity.24 For the I2
quality of the studies. The different domains were ‘low risk of bias,’ ‘high statistic, p < 0.10 was considered indicating significant heterogeneity.
risk of bias’ and ‘unclear risk of bias,’ as per the recommendations of
Cochrane Collaboration.24 Results

Data analysis and synthesis Study selection

We evaluated the impact of community-pharmacist-led medication The electronic database search identified 1932 potential studies for
review programmes on patients’ outcomes, including their clinical and inclusion in this study. A total of 145 additional studies were identified
healthcare service utilisation outcomes. The data were analysed using by searching reference lists. After the duplicate records were removed,
Cochrane Collaboration’s software Review Manager (RevMan 5.3). To 1450 studies were included in the screening of titles and abstracts. For
assess the effect size of dichotomous data, we reported such data as full-text screening, 222 studies were selected, and the 42 reports from 40
numbers and percentages. For the continuous data, we calculated the RCTs among them were included in the systematic review, and 12
weighted mean differences and the standardised deviation (SD) when studies were included in the meta-analysis. The search process and the
the outcomes were measured in the included studies using the same reasons for study exclusion are presented and discussed in detail in the
scale, and we calculated the standardised mean difference (SMD) when PRISMA flow diagram in Fig. 1.
different scales were used with SD in the included studies. We

Fig. 1. PRISMA flow diagram.

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Study characteristics Face-to-face interview was the most common method of conducting
medication review. Medication reviews were conducted face to face in
Table S2 (Supplementary Table) summarises all the studies that were 16 studies29,30,34,36,41,44,45,47,49,51,53,55,58,62–64 and by telephone in two
included in the systematic review in this study. In terms of country of studies28,31 while they were combined (face-to-face and telephone in­
origin, eight studies were conducted in the U.S.25–32; five each were terviews) in eight studies.32,35,43,50,54,57,59,60 The mode of delivery of the
conducted in Canada,33–37 the Netherlands38–42 and Australia43–47; and intervention was not clear in the remaining 14
four were conducted in the UK.48–51 Two studies each were conducted in studies.25–27,33,37–40,42,46,48,52,56,61
Spain43,51 and Germany,54,55 and only one study was conducted in In 31 studies, medication review programmes were delivered in
each of seven different European countries.56 Lastly, one study each was collaboration with the patient’s general practitioner (GP)/primary care
conducted in Iran,57 Jordan,58 Croatia,59 Iraq,60 Malta,61 Portugal,62 physician (PCP). For the rest of nine studies, it was not clear whether
Italy63 and Denmark.64 Almost all the studies except three46,48,63 patient’s GP was involved in the delivery of medication review
compared medication review programme with the control or the usual programme.25,28,33,45,51,52,54,57,60
care. The included studies were published within the period from 1997 In 22 studies, the intervention group received medication review as
to 2019. part of a multi-component intervention, whereas in the 18 other studies,
All the studies that were included in the systematic review in this the intervention group received solely pharmacist-led medication re­
study investigated the clinical outcomes (both disease-specific and non- view. Table S3 shows more information regarding intervention
disease-specific) whereas only 10 studies34,38,41,42,48,53,55,56,61,64 programmes.
assessed the health utilisation outcomes. Ten studies evaluated the
effectiveness of the medication review programme in elderly
Outcome measures
people,32,33,39,41,42,48,53,55,56,59 and six studies focused on asthma
patients.34,44,46,61,63,64 The average duration of the medication review
Both the clinical and health service utilisation outcomes were
programme offered in the included studies was six months (range: 10
assessed. All the studies that were included in the systematic review
weeks to 2 years).
evaluated more than one outcome (Table S2). The evaluated clinical
outcomes included both the disease-specific clinical outcomes (e.g. SBP
Risk of bias of the included studies and DBP, lipid profile, fasting glucose, HbA1c and cardiovascular risk)
and the non-disease-specific clinical outcomes (e.g. medication adher­
Overall, the risk of bias was generally variable across domains ence, DRP, adverse drug event(s), mortality and quality of life). The
(Figs. 2 and 3). The outcome assessors were blinded in only eight health services utilisation outcomes were emergency department visits,
studies.32,35,41,42,48,50,55,59 Only three studies28,33,39 had a high risk of hospital admissions and hospital re-admissions.
selection bias for random sequence generation, where the investigators For the meta-analysis, we statistically pooled data from 12 RCTs,
described the following non-random components in the sequence gen­ with a total of 4815 patients with chronic diseases. To ensure clinical
eration process: the last digit of the patient’s identification (ID) code, the homogeneity, we sub-grouped the data by population: hypertension,
first three digits of the pharmacy’s postal code and the sequence diabetes and dyslipidaemia. We pooled the SBP and DBP outcomes in the
generated by odd or even numbers. Furthermore, 17 studies did not hypertension and diabetes populations, but we statistically combined
adequately explain the methods of random sequence generation that only the HbA1c and total cholesterol (TC) outcomes in the diabetes and
they used. Only three studies37,41,50 described the allocation conceal­ dyslipidemia populations.
ment method that they used, but a lack of information on allocation
concealment was observed in most of the studies. Clinical outcomes
Additionally, we determined that approximately 50% of the studies
that were included in the systematic review in this study have a low risk Mortality. Three studies assessed the mortality as an outcome at
of attrition bias due to incomplete outcome data. Notably, a study pro­ different time points.38,41,55 Bouvy et al.38 reported a statistically
tocol was available for only seven studies.32,36,41,42,47,50,63 non-significant reduction in mortality among heart failure patients using
loop diuretics within the intervention group at 6 months with relative
Nature of medication review programmes risk of 0.6 (95% CI 0.3–1.4). However, the study was not sufficiently
powered to show effect on mortality. Similarly, study by Schulz et al.55,
The included studies showed that different names are used to not sufficiently powered to show effect on mortality, also reported a
describe community-pharmacist-led medication review programmes in non-significant reduction in mortality for elderly patients with chronic
different countries. In six studies, pharmaceutical care was the name of heart failure at 2-years in the intervention group (18%) compared to the
the programme.25,43,48,54,56,62 Medication therapy management (MTM) control (21%) (p = 0.55). However, Van der Meer et al.41 reported a
was used in the U.S.30,32 and Canada.37 In the Netherlands, there were slight increase, which was statistically non-significant, in mortality
two types of medication review programmes, one called among elderly patients with polypharmacy in the intervention group
community-pharmacist-led medication review programme39 and the compared to the control group at 3-months in their study (1.3% vs.
other called clinical medication review (CMR) programme.40,42 1.2%, p = 0.732).

Fig. 2. Risk-of-bias graph in the included trials (n = 40) across the domains.

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Fig. 3. Risk-of-bias summary across the individual trials = unknown risk, = high risk, fx10 = low risk.

Blood pressure (BP). BP was assessed as an outcome measure in 13 (increase in SBP and decrease in DBP) in one study36 and negative effects
studies, reported as SBP, DBP and the number of participants who in two studies in diabetes patients.29,57 Furthermore, the participants in
reached their BP goal levels.29–31,36,37,43,47,49,51,52,57,58,62 Ten studies the medication review programme arm achieved their BP targets across
investigated BP in hypertension patients,30,31,36,37,43,47,51,52,58,62 eight all the four studies that reported such outcome.30,31,37,52
investigated it in diabetes patients29–31,37,43,49,57,58 and four investi­ We pooled data on SBP using meta-analysis. For this, we included
gated it in dyslipidaemia patients.36,37,43,52 nine studies, three of which were conducted among hypertension pa­
For the overall BP outcome in the 13 studies, medication review had tients and six among diabetes patients. Overall, compared to the control
a positive effect in 10 studies,30,31,37,43,47,49,51,52,58,62 mixed effects group, there was a statistically significant reduction in SBP in the

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intervention group, with a − 6.56 (95% CI -10.05, − 3.08) MD. This level36,43,49,58 and two reported the percentage of patients who achieved
corresponds to a 6.56 mm Hg reduction in SBP. However, we found their HbA1c goals.31,37
statistically significant reduction for the diabetes patients (MD -6.82; All the six studies that reported the HbA1c levels showed constant
95% CI -11.33, − 2.32) and not statistically reduction with hypertension improvement in the result of HbA1c in medication review programme
patients (MD -6.21; 95% CI -13.26, 0.85) (Fig. 4). participants with various chronic diseases (diabetes, hypertension and
We pooled data for DBP using meta-analysis for nine studies. Overall, dyslipidaemia), compared to the control. Similarly, the blood glucose
we found a statistically significant reduction in the intervention group levels decreased at the follow-up points in all the four studies that re­
(MD -1.68; 95% CI -3.18, − 0.18) compared to the control group (Fig. 5). ported the blood glucose levels as an outcome. Moreover, the percentage
This effect is equivalent to a 1.68 mm Hg reduction in DBP. of patients in the medication review programme group who met their
HbA1c goal was significantly higher at follow-up compared to the
Lipid profile. The lipid profile was measured in 11 studies, but these control. In the study by Planas et al.,31 nearly half of the individuals
studies reported various components of the lipid (46.7%) in the intervention group achieved their HbA1C goal at 9
profile.26,29,31,36,37,43,45,49,52,58,60 Seven studies reported the months compared with only 2% in the control group (p = 0.002).
low-density lipoprotein (LDL) cholesterol levels,26,29,31,36,37,49,60 seven Tsuyuki et al.37 also reported an increase in the percentage of medica­
studies reported the total cholesterol (TC) levels,26,36,43,45,49,52,60 six tion review programme participants who achieved their HbA1C goals in
studies reported the triglyceride (TG) levels26,36,43,49,58,60 and five 3 months (42.2%) compared to the control (24.6%; p < 0.001).
studies reported the high-density lipoprotein (HDL) cholesterol We pooled data from six studies to estimate the effect of community-
levels.26,36,43,49,60 Two studies reported the participants who reached pharmacist-led medication review on patients’ HbA1c levels (Fig. 7).
their LDL goals31,37 and one study each reported the patients who ach­ The meta-analysis showed a statistically significant improvement in the
ieved their cholesterol goals26 and those who achieved their TC goals.52 HbA1c levels from the 591 diabetic patients enrolled in the medication
The lipid profile was measured in either mg/dL or mmol/l, but the first review programmes (MD -0.61; 95% CI -0.96, − 0.25, P 0.0008).
author (BA) converted all the units to mmol/l.
In all the seven studies that reported the LDL cholesterol levels of Cardiovascular risk. Only one study assessed the cardiovascular (CV)
their subjects, the community-pharmacist-led medication review had a risk.37 The adult patients with a high risk for CV events who were
positive effect on the LDL level at follow-up. Of the seven studies, six involved in the medication review programme for 3 months reported a
reported a reduction in TC levels at follow-up. Nola et al.26 reported an decrease in their estimated CV risk compared to the baseline (the mean
increase in the mean TC levels throughout the study period for both the changed from 25.6 to 20.5).
intervention and control groups. The mean TC levels increased by 0.11
mmol/l for the intervention group and by 0.25 mmol/l for the control Drug-related problems (DRPs). DRPs were reported in six studies, but
group. For the TG level, five studies showed a reduction during the these studies used different definitions and identification
follow-up period.26,36,43,58,60 Ali et al.49 revealed an increase in the TG methods.25,27,32,35,39,56 Currie et al.25 measured the DRPs by reviewing
level in the diabetes patients at one-year follow-up in both the inter­ the patients’ medication profiles, and they identified eight categories of
vention and control groups (0.17 mmol/l and 0.34 mmol/l, respec­ DRPs. In the study by Mott et al.,32 variables related to the character­
tively). Of the five studies that assessed the HDL level, three showed istics of the medication-related problems of fall-risk-increasing drugs
improvement during follow-up.26,43,49 However, two studies related to (FRIDs) were reported and measured by reviewing the patients’ medi­
dyslipidaemia patients reported lower HDL levels in both groups.36,60 cation profiles.
Two studies reported the percentage of patients who achieved their In the study by Bernsten et al.,56 data on the DRPs were collected
cholesterol goal.26,52 In both studies, the percentage was higher in the through self-completed questionnaires developed for use in the study.
intervention group than in the control group. McDonough et al.,27 on the other hand, used the Outcomes Encounter
Data were pooled for the TC outcome using meta-analysis. For the Program to identify and address five types of DRPs, but they collected
other outcomes (LDL, TG and HDL), they were deemed clinically het­ data on DRPs from the patients via a web-based survey that the patients
erogeneous and were not combined statistically. As shown in Fig. 6, data completed in the pharmacy.
for TC in dyslipidaemia patients were pooled in three studies. The In the study by Beaucage et al.,35 DRPs were categorised to six
medication review programme improved the TC level in 379 dyslipi­ different categories for oral antibiotic treatment, and were identified
daemia patients (MD -0.18; 95% CI -0.32, − 0.05; p = 0.008; I2 = 0%). based on a pharmacist’s analysis of the antibiotic prescription and in­
formation gathered from the patient and his or her pharmacy records
Fasting glucose and HbA1c levels. Six studies reported the HbA1c level as without specific script or algorithms. In the study by Vinks et al.,39 DRPs
an outcome,29,31,37,43,49,57 four reported the blood glucose were identified and validated by referring to the national prescribing

Fig. 4. Meta-analysis of SBP in hypertension and diabetes patients.

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Fig. 5. Meta-analysis of DBP in hypertension and diabetes patients.

Fig. 6. Meta-analysis of TC level in dyslipidaemia patients.

Fig. 7. Meta-analysis of the HbA1c level in diabetes patients

guidelines, and a drug utilisation profile was used to collect data on the patients to report the common symptoms that they felt in clinical
DRPs. medication reviews (CMRs). A reduction in the mean of drug-associated
For the effect of the medication review programme on the DRP symptoms (DASs) was revealed after 3 months (incidence rate ratio
outcome, Bernsten et al.56 and Vinks et al.39 showed that the programme [95% CI 0.90 [0.62–1.33]), along with a reduction in the percentage of
had a positive effect on DRPs throughout the study. In the study by Mott patients reporting at least one DAS (odds ratio 95% CI 0.85
et al.,32 the number of DRPs decreased in the intervention group [0.38–1.88]).
compared to the control group at 6-month follow-up. However, the The follow-up in the studies by Currie et al.25 and Beaucage et al.35
study by Beaucage et al.35 reported an increase in the number of DRPs in revealed that the percentage of patients in the medication review pro­
the intervention group compared to the control group. The studies by gramme who suffered from adverse drug reactions was higher than that
Currie et al.25 and McDonough et al.27 could not be used due to the in the patients who were receiving the usual care.
incomplete reporting of data.
Medication adherence. Medication adherence was assessed in 16 studies,
Adverse drug events (ADEs). Four studies reported ADEs.25,35,40,41 The but these studies used different questionnaires for such. The Morisky
authors used different methods of measuring ADEs, which resulted in Medication Adherence Scale (MMAS-8) was commonly used,47,50,57,63
different reports. In the study by Van der Meer et al.,41 the patients in the followed by the Brief Medication Questionnaire (BMQ).44,46 The Medi­
intervention reported felt less sedative side effects at 3-month follow-up cation Adherence Report Scale (MARS) was used in one study.45 Schulz
compared to the baseline (median [IQR] 3.0 [5.0] to − 1.0 [-2.0]), and et al.55 calculated medication adherence using the proportion of days
fewer anticholinergic side effects (median [IQR] 17.0 [22.0] to − 3.0 covered (PDC). Falamić et al.59 measured medication adherence through
[1.0]). pillbox count, and Bouvy et al.38 measured it through medication event
Schoenmakers et al.40 utilised ‘Patient-Reported Outcome Measure, monitoring systems (MEMS).
Inquiry into Side Effects’ (PROMISE), the instrument developed for The medication adherence outcome was reported as a change from

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baseline,30,33,44,46,47,56,57,63 and the intervention group was compared indicate that such programmes have a positive impact on patients’
to the control group at certain follow-up points.28,35,36,38,50,55,59 One clinical and healthcare service utilisation outcomes in patients with
study45 did not report the results for medication adherence outcome. long-term conditions.
Overall, medication review programmes had a positive effect on Our search strategy identified 40 studies that met the study inclusion
medication adherence outcome in the patients with chronic diseases and criteria, including studies that originated from a wide range of inter­
in elderly patients. However, one study33 reported a decrease in the national geographical regions. In such studies, the medication review
mean adherence score at the one-year follow-up (0.53 ± SD 0.77) programme was presented under more than 30 different names, despite
compared to baseline (0.56 ± SD 0.75) after improvement at six-month differing nomenclature, pharmacist medication expertise has been
follow-up (0.48 ± SD 0.65). recognized as a valuable contribution towards improving patient clinical
outcomes.
Quality of life. Sixteen studies assessed quality of life (QoL) but used The RCTs that were included in this study involved patients with
different questionnaires and scales for such. The short-form 36 (SF-36) various chronic diseases (e.g. hypertension, diabetes, dyslipidaemia,
questionnaire is the most commonly used tool for assessing asthma) and elderly patients, demonstrating that community-
QoL.33,48,54,56,60,61 EuroQol-5 Dimension-3 Level/5 Level pharmacist-led medication review is useful for patients with different
(EQ-5D-3L/5L) was used in three studies.41,42,53 Disease-specific QoL types of chronic conditions. As mentioned earlier, patients with chronic
questionnaires were used in six studies.44,46,49,55,61,64 The other ques­ diseases often require polypharmacy, and this can lead to DRPs, which
tionnaires that were used were the Juniper Questionnaire,34 the Not­ are preventable with careful medication review.1–3 Additionally,
tingham Health Profile (NHP)64 and the Dartmouth Primary Care improvement in patient outcomes appeared to occur irrespective of the
Cooperative Information Project/World Organization of National Col­ length of intervention across the included studies whose duration
leges, Academies Academic Associations of General Practice/Family ranged from 10 weeks to two years, which gives a wide window for the
Physicians Questionnaire (COOP/WONCA).38 programme duration to be implemented.
Eleven studies34,38,42,44,46,49,53,55,60,61,64 showed the positive impact The current review noted that there were methodical limitations in
of the medication review programme on QoL. Two studies33,54 showed the identified studies. The risk of bias was assessed for all the included
mixed results, with the different domains having different effects on the studies, although there were numerous missing data, resulting in
QoL. On the other hand, the QoL worsened in three studies.41,48,56 insufficient information for assessing a low or high risk of bias. This
suggests that there is a need for better-designed RCTs evaluating pa­
Health services utilisation tients’ outcomes in community pharmacy practice, in addition to the
need to improve the reporting of patient outcomes by following the
Emergency department visits. Hospital emergency department visits were Consolidated Standards of Reporting Trials (CONSORT) guideline.65 The
assessed in five studies.34,42,47,53,64 Of these five studies, one study methods section should clearly describe all key components to allow
showed a negative42 impact of medication review on the number of readers to make informed decision about various biases including per­
emergency visits after six-month follow-up while the remaining studies formance, selection and detection bias. Authors planning to undertake
demonstrated a positive effect of the programme at six-month and RCTs evaluating the effectiveness of pharmacist-led interventions
one-year follow-up. should consider publishing protocols in peer-reviewed journals,
enhancing transparency and validity of their findings.
Hospital admissions/re-admissions. Hospitalisation was assessed in nine Generally, there is lack of extensive evidence supporting impact of
studies34,38,41,42,53,55,56,61,64 and was reported as hospitalisation rate, community pharmacists’ interventions on reducing mortality. In this
percentage of participants with at least one hospital admission and review, the effect of medication review on mortality was inconclusive as
length of hospital stay. Five studies reported hospitalisation by hospi­ the trials were not either powered sufficiently38,55 or lacked long-term
talisation rate.38,41,53,55,64 Three studies reported the percentage of follow-up data41,55 to draw any meaningful conclusion from available
participants with at least one hospital admission53,56,61 while four data. Well-designed long-term clinical trials are required to demonstrate
studies measured the length of hospital stay.34,38,42,61 an impact on mortality, if any.
Of the five studies that reported hospitalisation rate outcomes, four In general, the number of drug related problems were more
reported a positive effect of community-pharmacist-led medication re­ commonly reported in the intervention group compared to the control.
view on hospitalisation rate.41,53,55,64 However, Bouvy et al.38 recorded We attribute this to a higher propensity for pharmacists to identify,
improvements in the total hospitalisation and planned re-admission document and report ADEs. This can be counted as a positive outcome
while recording a high rate of other hospital admissions in the inter­ overall in terms of effectiveness of intervention. There is a lot of evi­
vention group compared to the control group at six-month follow-up. dence which suggests that pharmacists play an important role of iden­
Two studies showed a reduction in admission days.34,61 However, tification and reporting of ADEs.66 This can be attributed to the
Verdoorn et al.42 reported a reduction in acute admission days but an pharmacist spending additional time with the patient and using a sys­
increase in planned admission days. In the study by Bouvy et al.,38 the tematic process to review patients’ medications.
total number of admission days was higher in the intervention group The meta-analysis showed a statistically significant improvement in
than in the control group at six-month follow-up (465 days and 332 clinical outcomes such as the SBP, DBP, HbA1c, and TC levels in the
days, respectively), and the planned re-admission days improved in the intervention group compared to the control group. However, careful
patients in the intervention group compared to those in the control consideration must be given to the clinical significance of these findings.
group (25 days and 37 days, respectively). Our meta-analysis revealed that a clinically significant reduction in SBP
(i.e. 6.56 mm Hg) was achieved in the hypertension and diabetes pa­
Discussion tients. A 2002 meta-analysis involving one million adults reported that
every 1 mm Hg reduction in SBP could prevent about 10,000 deaths
Main results related to coronary heart disease each year. Thus, health systems
adopting and implementing community-pharmacist-led medication re­
This systematic review/meta-analysis was undertaken to specifically view programmes can prevent over 60,000 deaths related to coronary
assess the effectiveness of community-pharmacist-based medication re­ heart disease alone.67
view programmes with a wide range of targeted outcomes among There is uncertainty, however, regarding the clinical significance of
different patient population groups. The main findings of this review the results of the studies included in this review on the benefits of the
community-pharmacist-led medication review programme for DBP,

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B. Al-babtain et al. Research in Social and Administrative Pharmacy xxx (xxxx) xxx

which was reduced by only 1.68 mm Hg. This limits the wider clinical medication on mortality among patients with long-term diseases.
implementation of the programme because the results of the previous Future studies are required to assess the sustained impact of community-
analysis suggest that a sustained 2 mm Hg reduction in DBP would be pharmacist-led medication review programmes on the clinical outcomes
expected to result in a 6% reduction in the risk of developing coronary as well as the cost-effectiveness of these programmes.
heart disease, and a 15% decrease in the risk of developing stroke.68
Additionally, community-pharmacist-led medication review pro­ Funding
grammes were found to have a clinical effect on HbA1c, with a − 0.61
MD, exceeding the 0.5 effect size for a pharmacist-based diabetes The study was self-funded.
management service, as calculated from studies on such services re­
ported in the Wubben and Vivian review. Although A1C is considered a Conflicts of interest
short-term surrogate outcome, it results in long-term reductions in
clinically important microvascular complications, and in improved There are no competing interests to declare.
quality of life.69
Appendix A. Supplementary data
Limitation
Supplementary data related to this article can be found at https://
This systematic review/meta-analysis had some limitations that doi.org/10.1016/j.sapharm.2021.04.022.
should be noted. First, only the studies published in English were
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