Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs, and patient outcomes.

BACKGROUND: In recent years pharmacists' roles have expanded from packaging and dispensing medications to working with other health care professionals and the public. OBJECTIVES: To examine the effect of expanding outpatient pharmacists' roles on health services utilisation, costs, and patient outcomes. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE, EMBASE, Pharmline, and International Pharmaceutical Abstracts (January 1966 to March 1999), the published abstracts of three meetings, hand searched five journals and two bibliographies, and reference lists of articles. SELECTION CRITERIA: Randomised trials, controlled clinical trials, controlled before and after studies and interrupted time series analyses comparing 1. Pharmacist services targeted at patients versus services delivered by other health professionals; 2. Pharmacist services targeted at patients versus the delivery of no comparable service; 3. Pharmacist services targeted at health professionals versus services delivered by other health professionals; 4. Pharmacist services targeted at health professionals versus the delivery of no comparable service. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Twenty-five studies were included involving more than 40 pharmacists and 16,000 patients. For comparison 1 (one study), scheduled service utilisation was slightly increased, whereas hospital admissions and emergency room admissions were decreased. For comparison 2, pharmacist services decreased the use of non-scheduled health services, the number of specialty physician visits or the number and costs of drugs, compared to control patients (six studies). Improvements in the targeted patient condition were reported in 10 of 13 studies that measured patient outcomes but patients' quality of life did not seem to change. For comparison 3 (one study), the intervention delivered by the pharmacist was less successful than that delivered by physician counsellors in decreasing inappropriate prescribing. For comparison 4, all studies demonstrated that pharmacist interventions produced the intended effects on physicians prescribing practices. The one study measuring patient outcomes was unable to show a difference in patients' quality of life. REVIEWER'S CONCLUSIONS: Only two studies compared pharmacist services with other health professional services. Both had some bias and did not allow us to draw conclusions about comparisons 1 and 3. The other studies supported the expanded roles of pharmacists in patient counselling and physician education. However, doubts about the generalisability of the studies, the poorly defined interventions, and the lack of cost assessments and patient outcome data, indicate that more rigorous research is needed to document the effects of outpatient pharmacist interventions.