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DIABETES

Sensitivity of Patient Outcomes to Pharmacist Interventions. Part I: Systematic Review and Meta-Analysis in Diabetes Management

at time of writing, PhD Candidate, Facultad de Ciencias Químicas y Farmacéuticas, Universidad de Chile, Santiago, Chile; Research Fellow, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada

Jana Bajcar, MSc

Associate Professor, Leslie Dan Faculty of Pharmacy, University of Toronto

Giovanni C Guzzo, MSc, PhD Candidate

Faculdade de Ciências Médicas, Universidade de Campinas, Campinas, Brazil

Thomas R Einarson, PhD

Associate Professor, Leslie Dan Faculty of Pharmacy, University of Toronto

Reprints: Dr. Einarson, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St., Toronto, ON M5S 3M2, Canada, fax 416/978-8511, t.einarson{at}utoronto.ca

BACKGROUND: Pharmacists participate in managing diabetes therapy. Despite many reviews, few have quantified the impact of pharmacists' interventions.

OBJECTIVES: To identify outcomes sensitive to pharmacists' interventions and quantify their impact through critical literature review.

METHODS: All original research describing the impact of pharmacists' interventions in the management of diabetic pharmacotherapy was sought in International Pharmaceutical Abstracts, MEDLINE, Embase, Cochrane Register, and Cumulative Index to Nursing & Allied Health Literature from inception through 2006. Two independent reviewers identified articles, compared results, and settled differences through consensus. The Downs-Black scale was used to assess quality. Data included intervention type, patient numbers, demographics, study characteristics, instruments used, data compared, and outcomes reported. A random-effects meta-analysis combined amenable results.

RESULTS: Of 302 articles identified, 108 involved pharmacists' interventions; 36 addressed diabetes (14 medical clinics, 11 community pharmacies, 7 ambulatory care clinics, 4 hospital wards, 1 physician's office, 1 prison, and 3 in both medical clinics and community pharmacies; 1 did not describe its practice site). Research designs included randomized (n = 18) and nonrandomized (n = 9) controlled trials, pre- and postobservational cohorts (n = 2), retrospective cohort study (n = 1), chart reviews (n = 5), and database study (n = 1). Diabetes education (69%) and medication management (61%) were the most frequently used interventions. Mean ± SD quality was 62 ± 11% (fair). Fifty-one (69%) study results were sensitive. Meta-analysis of data from 2247 patients in 16 studies found a significant reduction in hemoglobin A_1C (A1C) levels in the pharmacists' intervention group (1.00 ± 0.28%; p < 0.001) but not in controls (0.28 ± 0.29%; p = 0.335). Pharmacists' interventions further reduced A1C values 0.62 ± 0.29% (p = 0.03) over controls.

CONCLUSIONS: A1C is sensitive to pharmacists' interventions. Several potentially sensitive outcomes were identified, but too few studies were available for quantitative summaries. More research is needed.

Key Words: diabetes, glycemic control, glycosylated hemoglobin, pharmacist intervention

Published Online, August 21, 2007. www.theannals.com, DOI 10.1345/aph.1K151