Clinical pharmacists are uniquely trained in therapeutics and provide comprehensive drug management to patients and providers (includes physicians and additional members of the care team). Pharmacist intervention outcomes include economics, health-related quality of life, patient satisfaction, medication appropriateness, adverse drug events (ADEs), and adverse drug reactions (ADRs). An ADE is defined as "an injury resulting from medical intervention related to a drug," and an ADR is defined as "an effect that is noxious and unintended and which occurs at doses used in man for prophylaxis, diagnosis, or therapy." Reviews have been published about clinical pharmacy services in various settings, including ambulatory care, geriatrics, psychiatry, critical care, economic outcomes, and health-related quality of life, and a comprehensive review was published in 1986. To our knowledge, no previous reviews have focused specifically on clinical pharmacist interventions in the inpatient setting. This type of review is of particular importance because most studies reporting medication errors and ADEs were in hospitalized patients, and with the growth of hospital medicine,13 there is increased focus on interventions to improve the care of hospitalized patients. Benefits of clinical pharmacists have also been used to support expansion of their scope of practice.
Two recent Institute of Medicine reports recognized that pharmacists are an essential resource in safe medication use, that participation of pharmacists on rounds improves medication safety, and that pharmacist-physician-patient collaboration is important.15-16 In a recent survey, 30% of hospitals (74% of hospitals with >400 beds) reported that pharmacists attend rounds, and the rate is increasing.17 The role of clinical pharmacists differs from that of traditional pharmacists in that they work directly with providers and patients to provide services not simply associated with dispensing of drugs. Many clinical pharmacists have completed residencies and are board certified in specialty areas such as pharmacotherapy, oncology, nutrition, and psychiatry. This qualitative systematic review evaluates the published literature on the effects of pharmacist interventions in controlled trials in hospitalized patients.
PATIENT CARE UNIT PHARMACIST PARTICIPATION ON ROUNDS
Two studies involved the intensive care unit (ICU). Leape et al18 implemented a trial of pharmacist participation in a medical ICU, comparing ADE rates before and after intervention and with a control ICU. Preventable ADEs decreased by 66%, from 10.4 per 1000 patient-days before the intervention to 3.5 patient-days after the intervention (P<.001), with no change in the control ICU, from 10.9 per 1000 patient-days before the intervention to 12.4 per 1000 patient-days after the intervention (P = .76). Actual ADEs also decreased in the study ICU, from 33.0 to 11.6 per 1000 patient-days (P<.001), with an increase in the control ICU, from 34.7 to 46.6 per 1000 patient-days (P<.001). In a medical progressive care unit, Smythe et al19 implemented a clinical pharmacist–structured evaluation of 131 patients during 8 weeks and reported fewer ADRs compared with baseline (1 vs 8 events; P = .03); ICU transfer, readmission rate, and hospital length of stay (LOS) did not differ between baseline and intervention.
Eight studies20-27 assessed clinical pharmacists on general medicine, surgery and psychiatry services. Bjornson et al20 evaluated a clinical pharmacist intervention involving medication reconciliation, drug therapy plans, and discharge counseling. Intervention teams had fewer patients transferred for more intensive care and their patients had shorter LOS, but hospital readmissions and mortality did not differ. There were more ADRs in the intervention group (1.7%) compared with the control group (0.5%), but no P value was reported. The authors attribute this to a higher propensity for pharmacists to document ADRs. Scarsi et al21 compared results in patients when a pharmacist participated on rounds with an inpatient medicine team compared with patients who received pharmacist services only on the first day of hospitalization or when requested. These authors reported reductions in medication errors, number of patients without a medication error during hospitalization, and duration that an error persisted once it occurred.
One of the first intervention trials of clinical pharmacists on patient care units by Clapham et al22 involved regular interaction with physicians, patients, and nurses compared with the more traditional role of centralized pharmacy drug monitoring. The intervention reduced total average cost ($1293; P<.05) and produced nonsignificant reductions in LOS and drug costs, and pharmacists found working on the patient care area more professionally rewarding. In similar studies by Haig and Kiser23 and Boyko et al,24 inclusion of pharmacists on general medical teams resulted in reductions in LOS and in hospital and pharmacy costs. Kucukarslan et al25 found that a clinical pharmacist on the medicine team reduced preventable ADEs by 78%, but the number of events was small (2 vs 9; P = .02). The intervention was well accepted by physicians, with 98% of pharmacist recommendations accepted.
Owens et al26 assessed a geriatric team pharmacist and found that the intervention resulted in fewer medications by day 3 (P<.05), with the greatest reduction in patients in nursing homes. Medication use was increased by day 3 in 40% of subjects in the control group vs 18% of patients in the intervention group (P<.005), and control subjects received more medications without indications (19% vs 11%; P<.025) and inappropriate medications (37% vs 20%; P<.005), with no difference in number of medications at 6 weeks and 3 months. In the 1 inpatient psychiatry study, Canales et al27 showed significant improvements in clinical response (measured by psychiatric scales) and extrapyramidal symptoms, with no difference in medication costs and LOS.
Two recent Institute of Medicine reports recognized that pharmacists are an essential resource in safe medication use, that participation of pharmacists on rounds improves medication safety, and that pharmacist-physician-patient collaboration is important.15-16 In a recent survey, 30% of hospitals (74% of hospitals with >400 beds) reported that pharmacists attend rounds, and the rate is increasing.17 The role of clinical pharmacists differs from that of traditional pharmacists in that they work directly with providers and patients to provide services not simply associated with dispensing of drugs. Many clinical pharmacists have completed residencies and are board certified in specialty areas such as pharmacotherapy, oncology, nutrition, and psychiatry. This qualitative systematic review evaluates the published literature on the effects of pharmacist interventions in controlled trials in hospitalized patients.
PATIENT CARE UNIT PHARMACIST PARTICIPATION ON ROUNDS
Two studies involved the intensive care unit (ICU). Leape et al18 implemented a trial of pharmacist participation in a medical ICU, comparing ADE rates before and after intervention and with a control ICU. Preventable ADEs decreased by 66%, from 10.4 per 1000 patient-days before the intervention to 3.5 patient-days after the intervention (P<.001), with no change in the control ICU, from 10.9 per 1000 patient-days before the intervention to 12.4 per 1000 patient-days after the intervention (P = .76). Actual ADEs also decreased in the study ICU, from 33.0 to 11.6 per 1000 patient-days (P<.001), with an increase in the control ICU, from 34.7 to 46.6 per 1000 patient-days (P<.001). In a medical progressive care unit, Smythe et al19 implemented a clinical pharmacist–structured evaluation of 131 patients during 8 weeks and reported fewer ADRs compared with baseline (1 vs 8 events; P = .03); ICU transfer, readmission rate, and hospital length of stay (LOS) did not differ between baseline and intervention.
Eight studies20-27 assessed clinical pharmacists on general medicine, surgery and psychiatry services. Bjornson et al20 evaluated a clinical pharmacist intervention involving medication reconciliation, drug therapy plans, and discharge counseling. Intervention teams had fewer patients transferred for more intensive care and their patients had shorter LOS, but hospital readmissions and mortality did not differ. There were more ADRs in the intervention group (1.7%) compared with the control group (0.5%), but no P value was reported. The authors attribute this to a higher propensity for pharmacists to document ADRs. Scarsi et al21 compared results in patients when a pharmacist participated on rounds with an inpatient medicine team compared with patients who received pharmacist services only on the first day of hospitalization or when requested. These authors reported reductions in medication errors, number of patients without a medication error during hospitalization, and duration that an error persisted once it occurred.
One of the first intervention trials of clinical pharmacists on patient care units by Clapham et al22 involved regular interaction with physicians, patients, and nurses compared with the more traditional role of centralized pharmacy drug monitoring. The intervention reduced total average cost ($1293; P<.05) and produced nonsignificant reductions in LOS and drug costs, and pharmacists found working on the patient care area more professionally rewarding. In similar studies by Haig and Kiser23 and Boyko et al,24 inclusion of pharmacists on general medical teams resulted in reductions in LOS and in hospital and pharmacy costs. Kucukarslan et al25 found that a clinical pharmacist on the medicine team reduced preventable ADEs by 78%, but the number of events was small (2 vs 9; P = .02). The intervention was well accepted by physicians, with 98% of pharmacist recommendations accepted.
Owens et al26 assessed a geriatric team pharmacist and found that the intervention resulted in fewer medications by day 3 (P<.05), with the greatest reduction in patients in nursing homes. Medication use was increased by day 3 in 40% of subjects in the control group vs 18% of patients in the intervention group (P<.005), and control subjects received more medications without indications (19% vs 11%; P<.025) and inappropriate medications (37% vs 20%; P<.005), with no difference in number of medications at 6 weeks and 3 months. In the 1 inpatient psychiatry study, Canales et al27 showed significant improvements in clinical response (measured by psychiatric scales) and extrapyramidal symptoms, with no difference in medication costs and LOS.
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