The report is a product of the VA/HSR&D Evidence Synthesis Program.
Pharmacist-Led Chronic Disease Management: Effectiveness and Harms Compared to Usual Care
A recent Evidence-based Synthesis Program (ESP) report found that pharmacist-led chronic disease management was generally similar to usual care across clinical outcomes that included urgent care/ER use and hospitalizations (moderate-strength evidence), disease-specific clinical events (low-strength evidence ), and non-adherence to medication (low-strength evidence). Evidence of patient satisfaction was insufficient and the results were inconsistent, although patients receiving pharmacist-led care had significant improvement in goal attainment for blood pressure, cholesterol, and glucose levels (moderate-strength evidence). (See Table for summary of the results.)
There has been speculation that increased involvement of clinical pharmacists in patient care may offer increased access to healthcare and improved patient outcomes. In these cases, pharmacists collaborate with health team members to optimize therapeutic outcomes by identifying, solving, and preventing actual and potential drug therapy problems. Since 1995, the Department of Veterans Affairs has allowed Clinical Pharmacy Specialists (CPS) an expanded scope of practice with independent prescribing privileges. In this capacity, CPS have been detailed to perform "pharmaceutical care" or comprehensive medication management along with chronic disease state management services, in addition to less complex services such as patient medication counseling or responding to drug information questions. In the VA primary care setting, CPS are likely to be responsible for therapeutic outcomes for a multitude of conditions for any Veteran referred to CPS or proactively identified by CPS as a high-risk patient.
This review was conducted by the ESP site at the Minneapolis VA Health Care System with the purpose of determining the effectiveness and harms of pharmacist-led chronic disease management for community-dwelling adults. Chronic disease management aims to control symptoms and slow or stop disease progression. Chronic disease management is typically a multi-component intervention that includes medication therapy review, patient medication education, medication monitoring, immunizations, disease self-care and support, and/or prescribing authority. This topic was nominated by Heather Ourth, PharmD, VACO Pharmacy Benefits Management Program Manager, on behalf of the National Clinical Pharmacy Research Group, chartered by the VACO Clinical Pharmacy Practice Office of VACO Pharmacy Benefits Management (PBM). The chronic disease conditions addressed in the included studies (cardiovascular disease, chronic kidney disease, COPD, depression, diabetes mellitus, and hypertension) are common among Veterans. Seventeen studies were conducted in VA facilities. The model of pharmacist-led care reported in these studies varied but likely is similar to ongoing programs in VA.
Overall, report authors concluded that evidence is limited on the effectiveness and harms of pharmacist-led chronic disease management compared with usual care for clinical outcomes, such as clinical events, all-cause mortality, patient satisfaction, quality of life, and resource utilization. Moderate-strength evidence indicates that pharmacist-led chronic disease management increases goal attainment for HbA1c, blood pressure, and cholesterol levels. The report found little reporting of access to care and drug-related problems. Authors note these results suggest that future programs are likely to achieve intended laboratory and physiologic goals. However, to accurately assess healthcare value, future research studies and implementation projects that utilize intermediate laboratory and physiologic goals as measures of effectiveness need to be certain that these goals are clearly linked to improved patient outcomes, including clinical events, satisfaction, access, hospitalizations, costs, medication adherence, and drug-related problems – without undue harms and costs.
This report did not address pharmacist coordination of care (i.e., VA and non-VA care or use of non-VA pharmacies for generic medications), topics that may be of increased interest to VACO PBM following introduction of the Veterans Access, Choice and Accountability Act of 2014.
Greer N, Bolduc J, Geurkink E, Koeller E, Rector T, Olson K, MacDonald R, and Wilt TJ. Pharmacist-led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared to Usual Care. VA ESP Project #09-009; 2015.
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A cyberseminar titled "Pharmacist-led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared to Usual Care" will be held on Wednesday, March 9, 2016 from 3:00pm to 4:00pm (EST). To register, please visit the HSR&D Cyberseminar site.
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ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
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