Community-based pharmacists

National Guideline Centre (UK)

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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)

Emergency and acute medical care in over 16s: service delivery and organisation.

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Chapter 10Community-based pharmacists

10. Community-based pharmacists

10.1. Introduction

Pharmacists are highly trained medical professionals, qualified to give advice on health issues and medicines, and ensure the safe supply and use of medicines by the public. Medicines prevent, treat or manage many illnesses or conditions and are the most common intervention in healthcare.

The traditionally role of pharmacists in the community has involved dispensing and supply of prescriptions that have been issued by doctors. However in recent years the role and locations from which pharmacists in the community (primary care) work from has evolved and pharmacists have been undertaking more clinical roles in addition to the traditional dispensing services.

Overall it would be of interest to see if there is evidence to support the clinical and cost-effective development of services by community based pharmacists.

10.2. Review question: Do enhanced roles of pharmacists in the community have clinical and cost-effectiveness benefits for patients at risk of an acute medical emergency or have a suspected or confirmed acute medical emergency?

For full details see review protocol in Appendix A.

Table 1

PICO characteristics of review question.

10.3. Clinical evidence

Thirty seven studies were included in the review;⁵^,⁶^,⁸^,¹⁷^,²⁷^,²⁹^,³⁰^,³⁹^,⁵³^,⁵³^,⁵⁴^,⁶³^,⁷⁹^,⁹¹^–⁹³^,¹⁰³^,¹¹⁵^,¹¹⁶^,¹²⁰^–¹²³^,¹²⁹^,¹³⁰^,¹³⁵^,¹⁴¹^,¹⁴⁶^,¹⁵¹^,¹⁶²^,¹⁷²^,¹⁷³^,¹⁷⁶^,¹⁸²^,¹⁸⁸^,¹⁸⁹^,¹⁹¹^,¹⁹²^,¹⁹⁸^,¹⁹⁹^,²⁰¹^,²⁰²^,²⁰⁵^,²⁰⁷^,²²⁷^,²²⁹^,²³⁰^,²³²^,²³³ these were split in 6 stratifications based on both type of pharmacist (community pharmacist or clinical pharmacist) and the location the intervention takes place. These stratifications are summarised in Table 2 to Table 7 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 8 to Table 13). See also the study selection flow chart in Appendix B, forest plots in Appendix C, study evidence tables in Appendix D, GRADE tables in Appendix F and excluded studies list in Appendix G.

Table 2

Summary of studies included in the review for the strata: community pharmacist based within a community pharmacy.

Table 7

Summary of studies included in the review for the strata: clinical pharmacist based within a GP practice.

Table 8

Clinical evidence summary: Community pharmacist based within a community pharmacy.

Table 13

Clinical evidence summary: Clinical pharmacist based within a GP practice.

Table 3

Summary of studies included in the review for the strata: community pharmacist at the patients’ homes.

Table 4

Summary of studies included in the review for the strata: community pharmacist based within a GP practice.

Table 5

Summary of studies included in the review for the strata: clinical pharmacist based within a community clinic.

Table 6

Summary of studies included in the review for the strata: clinical pharmacist at the patients’ homes.

Narrative findings

Ali 2012: adverse events (total hypoglycaemic and hyperglycaemic events) at 12 months was 5/23 in the intervention group and 28/23 in the control.

Respect trial team 2010: emergency admission episodes per month at 2 years was modelled with the intervention effect estimate (SE): 0.049 (0.290) and the time-intervention effect estimate (SE): −0.042 (0.038).

BC Community pharmacy study: emergency visits during baseline and month 12: intervention - baseline: 0.165, final: 0.043, change: −0.122; control - baseline: 0.377, final: 0.213, change: −0.164.

BC Community pharmacy study: medical visits during baseline and month 12: intervention - baseline: 1.328, final: 0.386, change: −0.942; control - baseline: 1.429, final: 1.730, change: 0.301.

BC Community pharmacy study: hospitalisations during baseline and month 12: intervention - baseline: 0.123, final: 0.078, change: −0.045; control - baseline: 0.143, final: 0.160, change: 0.017.

Gordois 2007 (Armour 200): total GP visits at 6 months: intervention 309/162; control 278/185.

Table 9

Clinical evidence summary: Community pharmacist at the patients’ homes.

Table 10

Clinical evidence summary: Community pharmacist based within a GP practice.

Table 11

Clinical evidence summary: Clinical pharmacist based within a community clinic.

Table 12

Clinical evidence summary: Clinical pharmacist at the patients’ homes.

10.4. Economic evidence

Published literature

Ten health economic studies were identified from eleven papers with the relevant comparison and have been included in this review.²⁶^,⁵³^,⁶¹^,⁶³^,⁷⁹^,⁹⁴^,¹⁰³^,¹⁵¹^,¹⁶¹^,¹⁷²^,¹⁹¹^,²¹⁴ These are summarised for each stratum in the health economic evidence profiles below (Table 14 to Table 17) and the health economic evidence tables in Appendix E.

Table 14

Health economic evidence profile: enhanced-role community pharmacists at community pharmacy versus usual care.

Table 17

Health economic evidence profile: enhanced-role clinical pharmacists at GP practice versus usual care.

Twelve economic studies relating to this review question were identified but were excluded due to a combination of limited applicability and methodological limitations or the availability of more applicable evidence. These are listed in Appendix H, with reasons for exclusion given.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

Table 15

Health economic evidence profile: enhanced-role community pharmacists at home versus usual care.

Table 16

Health economic evidence profile: enhanced-role community pharmacists at GP practice versus usual care.

10.5. Evidence statements

Clinical

Community pharmacist

Fourteen studies comprising 2413 participants evaluated the role of community pharmacists (community pharmacist’s strata) for improving outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that enhanced role of a community pharmacists may provide a benefit in reduced mortality (6 studies, very low quality), ED presentations (7 studies, low quality), mean ED presentations (1 study, low quality), GP visits (2 studies, very low quality) and hospital admissions (7 studies, very low quality) and mean number of hospitalisation (2 studies, moderate quality).

Three studies comprising 1254 participants evaluated the role of community pharmacists (patient’s home strata) for improving outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that home visits from a community pharmacist were associated with higher mortality (2 studies, low quality) and more hospital admissions (3 studies, low quality) but no effect on quality of life (2 studies, low quality).

Four studies comprising 3824 participants evaluated the role of community pharmacists (GP practice strata) for improving outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that the community pharmacist within a GP practice may provide a benefit in reduced hospital admissions (2 studies, very low quality). However, the evidence suggested there was no effect on survival (1 study, very low quality), ED presentations (1 study, very low quality), mean number of hospitalisations (1 study, high quality) and GP visits (1 study, high quality). The evidence suggested a possible increase in adverse events (1 study, very low quality) and mortality (3 studies, very low quality).

Clinical Pharmacist

Five studies comprising 2805 participants evaluated the role of clinical pharmacists (community clinics strata) for improving outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that clinical pharmacists provided a benefit in reduced mortality (4 studies, moderate quality), hospitalisations (1 study, moderate quality) and number of ED visits (2 studies, low quality). The evidence suggested there was no effect on the number of GP visits (2 studies, low quality) or mean number of hospitalisations (3 studies, low quality).

Four studies comprising 1765 participants evaluated the role of clinical pharmacists (patient’s home strata) for improving outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that home visits from a clinical pharmacist may provide a benefit in reduced hospital admission (3 studies; 2 report relative risk and 1 reports a hazard ratio, very low quality) and GP visits (1 study, very low quality). The evidence suggested that there was a possible increase in mortality (1 study, low quality) with clinical pharmacists.

Eight studies comprising 2581 participants evaluated the role of clinical pharmacists (GP practice strata) for improving outcomes in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that adverse events (2 studies, very low quality) and hospital admissions (4 studies reporting a relative risk, very low quality) were reduced by use of a clinical pharmacist but no difference was seen for GP visits (2 studies, low quality) or hospitalisations (1 study reporting a mean and 1 study reporting a hazard ratio (high quality). There was a possible decrease in mortality from 5 studies when reported as risk ratio (very low quality), but no difference from 1 study which reported a hazard ratio (high quality). There was a possible decrease in ED visits from 1 study which reported a dichotomous outcome (low quality), but no difference from one study which reported a continuous outcome (high quality).

Economic

Two cost-utility analyses found that enhanced-role community pharmacists at community pharmacies dominated usual care by reducing costs and improving health outcomes. Both studies were assessed as being partially applicable with potentially serious limitations.
One cost-effectiveness analysis found that enhanced-role community pharmacists at community pharmacies dominated usual care by reducing costs and improving health outcomes. The study was assessed as being partially applicable with potentially serious limitations.
Three cost-utility analyses found that enhanced-role community pharmacists at community pharmacies were cost effective compared to usual care (ICERs: £7,350; £2,121 and £10,000 per QALY gained). Two of these studies were assessed as being partially applicable with potentially serious limitations; one of these studies was assessed as being directly applicable with minor limitations.
One cost-utility analysis found that an enhanced role community pharmacist at the patient’s home was not cost effective (£54,454 per QALY) compared with usual care. The study was assessed as being partially applicable with potentially serious limitations.
One cost-utility analysis found that usual care was cost effective compared with community pharmacist at the patient’s home (£16,157 per QALY). The study was assessed as being partially applicable with potentially serious limitations.
One cost-effectiveness analysis found that enhanced-role community pharmacists at the GP surgery dominated usual care by reducing costs and improving health outcomes. The study was assessed as being partially applicable with potentially serious limitations.
One cost-utility analysis found that an enhanced-role clinical pharmacist at the GP surgery was cost effective compared to usual care (ICER: £5,567 per QALY gained). This study was assessed as being partially applicable with potentially serious limitations.

10.6. Recommendations and link to evidence

Recommendations	4. For people who are at increased risk of developing a medical emergency: provide advanced community pharmacy-based services consider providing advanced pharmacist services in general practices 5. For people at risk of an acute medical emergency, do not commission pharmacists to conduct medication reviews in the home unless needed for logistical or clinical reasons.
Research recommendations	-
Relative values of different outcomes	Mortality, avoidable adverse events, quality of life, patient and/or carer satisfaction, number of ED presentations and unplanned GP attendances were considered by the guideline committee to be critical outcomes. Hospital admissions were considered important outcomes.
Trade-off between benefits and harms	The review was separated into 6 strata split by both the provider of the intervention, either a community or clinical pharmacist, and the location. The locations of the intervention for the community pharmacist were at a community pharmacy, within the patient’s home, or within a GP practice. The locations of the intervention for the clinical pharmacist were at a community clinic, within the patient’s home, or within a GP practice. ‘Community clinic’ in this context refers to a service for patients with specific chronic conditions such as pulmonary disease or diabetes. Thirty seven studies from 56 papers were included overall. The majority of these contain some type of medication review and patient education intervention, though there was significant heterogeneity in the individual elements across the identified evidence. The majority of studies either recruited patients who had a specific long-term condition requiring medications, or a heterogeneous population taking varied medications. Several of the latter studies restricted the population to the elderly. Community pharmacist: Twenty one randomised controlled trials were included within the community pharmacist strata overall: Community pharmacist based within a community pharmacy Fourteen randomised controlled trials were included for the community pharmacy stratum with the evidence suggesting a benefit for enhanced roles for community pharmacists in reduced mortality, ED presentations, GP visits and hospital admissions. No evidence was identified for quality of life, GP attendances or patient and/or carer satisfaction. Community pharmacist at the patients’ homes Three randomised controlled trials were included for the ‘at patient’s home’ stratum. The evidence suggested that home visits from a community pharmacist were associated with higher mortality and more hospital admissions but no effect on quality of life. Community pharmacist based within a GP practice Four randomised controlled trials were included for the ‘within a GP practice’ stratum. The evidence suggested that the community pharmacist within a GP practice may provide a benefit in reduced hospital admissions. However, the evidence suggested there was no effect on survival, ED presentations, mean number of hospitalisations and GP visits. The evidence suggested a possible increase in adverse events and mortality. No evidence was identified for ‘quality of life or patient and/or carer satisfaction. Clinical Pharmacist Seventeen randomised controlled trials were included within the clinical pharmacist strata overall: Clinical pharmacist based within a community clinic Five randomised controlled trials were included for the ‘within a community clinic’ stratum. The evidence suggested that clinical pharmacists provided a benefit in reduced mortality, hospitalisations and number of ED visits. The evidence suggested there was no effect on the number of GP visits or hospitalisations (reported as a mean). No evidence was identified for avoidable adverse events, quality of life, or patient and/or carer satisfaction. Clinical pharmacist at the patients’ homes Four randomised controlled trials were included for the ‘at patient’s home’ stratum. The evidence suggested that home visits from a clinical pharmacist may provide a benefit in reduced hospital admission and GP visits. The evidence suggested a possible increase in mortality with clinical pharmacists. No evidence was identified for avoidable adverse events, ED visits, or patient and/or carer satisfaction. Clinical pharmacist based within a GP practice Eight randomised controlled trials were included for within a GP practice stratum. The evidence suggested that adverse events (serious adverse events) and hospital admissions (reported as a relative risk) were reduced by use of a clinical pharmacist but no difference was seen for GP visits or hospitalisations (reported as a mean and a hazard ratio). The outcomes were reported using different methods in the evidence. There was a possible decrease in mortality from 5 studies when reported as risk ratio, but no difference from 1 study which reported a hazard ratio. There was a possible decrease in ED visits from 1 study which reported a dichotomous outcome, but no difference from 1 study which reported a continuous outcome. No evidence was identified for quality of life or patient and/or carer satisfaction. The committee discussed this apparent inconsistency when making their recommendation, and noted that the higher quality evidence consistently showed no difference from using a clinical pharmacist in a GP practice. Overall The committee discussed the evidence and felt that given the body of evidence and consistency in benefit, a strong recommendation could be made for the enhanced use of community and clinical pharmacists with interventions based within the community pharmacy. The committee agreed that the evidence was generalisable to recommend for all people at increased risk of developing a medical emergency. Overall, there was evidence of effectiveness to consider introducing an advanced role for pharmacists within GP practices, however, without direct comparisons the committee were unable to make a judgement on the exact role or skills required when commissioning these services. The committee noted that there is a 3-year pilot study for clinical pharmacists in GP practice that has just started (The General Practice Forward View).¹⁵² The committee discussed the evidence concerning pharmacists travelling and performing an intervention within a patient’s home. They deemed that the evidence was weak, and often showed that these visits were detrimental compared to usual care (most often the usual service from a GP); even when clinical pharmacists were involved. They judged that a negative recommendation for the commissioning of services that take place at patients’ homes would be most appropriate at this time.
Trade-off between net effects and costs	Ten economic evaluations were included in this review, of which 6 were in the stratum of community pharmacists based in community pharmacies, 1 was a community pharmacist in a general practice, 1 was a clinical pharmacist in a general practice and 2 were for community pharmacists at the patient’s home. Community pharmacists For the community pharmacist interventions provided at a community pharmacy, the net costs ranged from cost saving to an increase in cost of £278 per patient. All the interventions showed a health benefit, which for all of the studies that showed an increase in costs was measured in QALYs, so cost effectiveness could be assessed. The ICERs went up to £10,000 per QALY and therefore this intervention was shown to be cost effective. Various sensitivity analyses showed that these results were robust to changes. The committee discussed the economic evidence and agreed that there is strong economic evidence to support the cost effectiveness of enhanced role community pharmacists’ interventions at community pharmacies. The interventions described in the studies covered conducting medicines’ use reviews and providing support for those starting on newly prescribed medicines. These interventions reflected the advanced services currently provided at community pharmacists in England, which have been established for some time and the accumulated evidence strongly support the continuation of their provision. Thus, the committee felt that enhancing the role of community pharmacists to allow the expansion in the provision of these services represents good value for money by improving health outcomes while being either cost saving or cost effective; with ICERs well below the cost effectiveness threshold. While all studies showed evidence of cost effectiveness, the ones in the UK (and in particular, the one study that was assessed as directly applicable and only minor limitations) indicated an increase in costs overall from this intervention. Pharmacists at GP practices For community pharmacist interventions at GP practices, 1 Canadian study showed that the intervention was dominant, as it led to saving of £102 per patient and improved health outcomes. However, the outcome was not measured in QALYs. For clinical pharmacist interventions at GP practices, 1 UK study showed the intervention was cost effective with an ICER of £5,567 per QALY gained. When the intervention was delivered by a prescribing pharmacist, the ICER increased to £11,304 per QALY gained. No evidence was found for clinical pharmacist interventions at any other community-based setting. The evidence for clinical pharmacists’ interventions was either positive or neutral in terms of health outcomes and has been shown to be cost effective. The committee noted that although there were no differences between prescribing and non-prescribing pharmacists based on the clinical evidence, 1 UK economic evaluation showed that prescribing pharmacists were not considered cost effective compared to non-prescribing pharmacists. The committee discussed this particular finding in detail and concluded that this could be due to the cost of the prescribing qualification, which would possibly require longer follow-up to be offset by improvement in outcomes. The committee also noted that both the interventions delivered by prescribing and non-prescribing pharmacists were still cost effective when compared to usual GP-delivered care, so did not believe that prescriber status should be specified in the recommendation. Overall, the committee felt that clinical pharmacist interventions provided at GP practices were at least as effective as usual care and could potentially have an additional positive impact on GPs’ workload by freeing up their time to focus on the more complex patients. The evidence from the clinical pharmacist role at community clinics, though not directly applicable to the UK setting, could also be extrapolated to the role at a GP practice. The committee was aware of the recently published GP Forward View, from NHS England, which supported this conclusion.¹⁵² The report outlined plans to provide an additional 1500 clinical pharmacists to join the GP practice workforce by 2020, acknowledging their role in the GP practice workforce and their expected positive impact on GPs’ workload. For community pharmacists’ interventions at GP practices, the evidence of health benefit was weaker, with some outcomes showing harm (adverse events and mortality). However, the committee noted that this was based on low quality evidence, and could be interpreted as indicating that community pharmacists would need more training, in terms of their clinical skills (for example, physical examination and history taking), and more time to integrate into the GP practice team in order to realise the benefit of their adoption of practice-based roles. The committee was aware of current initiatives by NHS England supporting extended roles for pharmacists, including the introduction of the Pharmacy Integration Fund. This includes the recent creation of a new role of a “Practice Pharmacist”, by which pharmacists from any practice background (hospital, community or primary care) could work at GP practices as long as they have the necessary skills and competencies. The committee also noted that, given the favourable economic evidence, the initial investment to enhance the skills of pharmacists to undertake these practice-based roles would show positive returns in the long term. Home setting For the community pharmacist interventions at the patient’s home, 2 UK studies had contradictory results in terms of costs and health outcomes but had the same conclusion regarding cost effectiveness. One study showed that the intervention was cost saving (saving £307 per patient) but led to reduction in quality of life (loss of 0.019 QALYs), despite increasing adherence by 10%. The ICER for usual care in this study was calculated to be £16,157 per QALY gained, indicating that the pharmacist intervention was not cost effective compared to usual care. The second study showed that the pharmacist intervention increased cost (£407 per patient) and had a relatively small increase in QALYs of 0.0075, which meant it was not cost effective with an ICER of £54,454 per QALY. The evidence of health benefit was contradictory and the economic evidence showed that these interventions were not cost effective. There was no economic evidence relating to the clinical pharmacist interventions at patients’ homes. Hence, the committee felt that these interventions should not be provided. The committee noted that the evidence, however, was primarily focused on visits to the patients’ homes and may not apply to pharmacists’ interventions at residential and care homes, the evidence for which was not specifically reviewed in this question. The committee was aware of on-going research in this area.
Quality of the evidence	Community pharmacist For the community pharmacy stratum the evidence was graded at low or very low due to a combination of risk of bias and imprecision. Three out of 4 outcomes containing a pooled estimate were further downgraded for inconsistency. These were the outcomes mortality, hospital admissions and GP visits. For the ‘at home’ stratum the majority of evidence was of moderate quality due to risk of bias, with the outcome mortality further downgraded for imprecision. For the ‘within a GP practice’ stratum the evidence was either very low or high quality, with evidence downgraded for a combination of risk of bias and imprecision. All economic studies of community pharmacists were assessed as partially applicable with potentially serious limitations. Clinical pharmacist For the clinical pharmacist in a community clinic stratum the evidence was graded at moderate or low due to risk of bias and/or imprecision. For the clinical pharmacist at patients home stratum the evidence was graded at low or very low due to a combination of risk of bias and imprecision. For the clinical pharmacist ‘within a GP practice’ stratum the majority of evidence was either very low or high quality, with evidence downgraded for a combination of risk of bias and imprecision. The outcomes mortality and hospital admissions were further downgraded for inconsistency. The committee assessed the applicability of evidence to the UK practice. In particular, they noted that the evidence supporting the use of clinical pharmacists working within a community clinic, such as a stand-alone haemodialysis clinic, would not be applicable to UK. Therefore, they judged that a recommendation in this area would not be appropriate. All economic studies of clinical pharmacists were assessed as partially applicable with potentially serious limitations.
Other considerations	Advanced community pharmacy based services are services such as the Medicines Use Reviews (MUR) and the New Medicines Service (NMS) as defined in the NHS Community Pharmacy Contractual Framework. Advanced pharmacist services in general practice are services such as level 3 clinical medication reviews where the pharmacist reviews the patient, illness and drug treatment during a consultation with access to patient notes, prescribing history, access to laboratory tests and with the patient present.¹⁹⁰ The committee noted that there is no clear distinction between a clinical pharmacist and a community pharmacist. Historically a community pharmacist has been based within a community pharmacy and a clinical pharmacist within a hospital ward; however, recently the distinction has become more blurred. The committee noted that within the studies identified, a community-based clinical pharmacist, particularly outside a GP practice, was more established in North America. The committee noted that in the future it is likely that these 2 roles are likely to diverge, even when located within the same setting, with the expectation that community pharmacists will concentrate on medication adherence and/or patient education and therefore supporting the role of the GP, whereas clinical pharmacists will have a greater clinical involvement with patients, therefore replacing the involvement of GPs in some situations. The committee noted that pharmacists should not be functioning in isolation and should be supported by other healthcare staff as appropriate, for example, the GP, hospital consultant or district/community nurse. In particular the committee judged that it would be more appropriate for a multi-disciplinary team led by other healthcare professionals, such as a district nurse, to be making home visits to patients, rather than a pharmacist but they could be supported by the pharmacist if needed. The committee noted that this review did not specifically look at care homes so this would not be included within the pharmacists ‘at home’ recommendation. The NICE guideline: Managing medicines in care homes (2014)¹⁴⁸ provides advice for this population group. The committee noted that the recommendations will be impacted by the General Practice Forward View published April 2016.¹⁵² This report recommends an additional 1500 clinical pharmacists to be based within GP practices by 2020/21. This includes the current investment of £31 million to pilot 470 clinical pharmacists in over 700 practices, and is to be supplemented by a new central investment of £112 million to extend the programme for all practices not in the initial pilot. This is to be further supplemented with an additional pharmacy integration fund¹⁵³ to enable all pharmacists to provide more direct care to patients by expanding the range of clinical services they offer and integrating them into local care models outlined in the Five Year Forward View. The fund, worth £20 million in 2016 rising to a total of £300 million by 2020-21, is intended to help pharmacists and their teams to be fully incorporated across NHS planning and service delivery. In addition, the DH launched a package of reforms in October 2016 to modernise community pharmacy services.⁶⁰ There is an ongoing National Urgent Medicines Supply Advanced Service pilot for community pharmacy that runs from 1^st December 2016 to 31^st March 2018. At the end of the pilot an evaluation will be conducted by NHS England to test and evaluate the service in order to inform possible future commissioning.

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Appendices

Appendix A. Review protocol

Table 18Review protocol: Do enhanced roles of pharmacists in the community have clinical and cost-effectiveness benefits for patients at risk of an acute medical emergency or have a suspected or confirmed acute medical emergency?

Review question	Community pharmacist
Guideline condition and its definition	Acute Medical Emergencies. Definition: people with suspected or confirmed acute medical emergencies or at risk of an acute medical emergency.
Review population	Adults or young people (>16 years of age) who are at risk of, or have a suspected or confirmed AME.
	Adults and young people (16 years and over).
	Line of therapy not an inclusion criterion.
Interventions and comparators: generic/class; specific/drug (All interventions will be compared with each other, unless otherwise stated)	Community pharmacists with enhanced roles in disease management; delivered at community clinics. Community pharmacists with enhanced roles in disease management; delivered at general practices. Community pharmacists with enhanced roles in disease management; delivered at patient’s home. Community pharmacists with enhanced roles in disease management; delivered at community pharmacy. Community pharmacists with enhanced roles in disease management; intervention delivered at other community-based location. Clinical pharmacists with enhanced roles in disease management; delivered at community clinics. Clinical pharmacists with enhanced roles in disease management; delivered at general practices. Clinical pharmacists with enhanced roles in disease management; Delivered at patient’s home. Clinical pharmacists with enhanced roles in disease management; delivered at community pharmacy. Clinical pharmacists with enhanced roles in disease management; intervention delivered at other community-based location. Usual care.
Outcomes	- Mortality within the study period (Dichotomous) CRITICAL - Avoidable adverse events (incorrect diagnosis and treatment) within the study period (Dichotomous) CRITICAL - Quality of life within the study period (Continuous) CRITICAL - Number of ED presentations within the study period (Dichotomous) CRITICAL - GP attendances within the study period (Dichotomous) CRITICAL - Hospital admissions within the study period (Dichotomous) IMPORTANT - Patient and/or carer satisfaction within the study period (Continuous) IMPORTANT
Review strategy	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Unit of randomisation	Patient. Pharmacist/Physician. Practice.
Crossover study	Permitted.
Minimum duration of study	Not defined.
Other stratifications	Type of pharmacist - clinical pharmacist, community pharmacist; location of the intervention.
Sensitivity/other analysis	Frail elderly. UK versus non-UK. Pre-specified study subgroups.
Subgroup analyses if there is heterogeneity	- Frail elderly (frail elderly; non-frail elderly); population differs. - UK versus non-UK (UK; non-UK); different practice. - Pre-specified study subgroups (pre-specified by study1; pre-specified by study 2); may be important. - Prescribing power (prescribing; non-prescribing); pharmacists who can prescribe may be more effective at community-based interventions.
Search criteria	Databases: Medline, Embase, the Cochrane Library. Date limits for search: 1990. Language: English.

Appendix B. Clinical study selection

Figure 1Flow chart of clinical study selection for the review of Community-based pharmacists

Appendix C. Forest plots

C.1. Community pharmacist based within a community pharmacy

Figure 2Mortality

Figure 3ED presentations

Figure 4ED presentations

Figure 5Hospital admissions

Figure 6Hospital admissions

Figure 7GP visits

C.2. Community pharmacist at the patients’ homes

Figure 8Mortality

Figure 9Hospital admissions

Figure 11Quality of Life (EQ-5D)

Figure 12Quality of Life (EQ-VAS)

C.3. Community pharmacist based within a GP practice

Figure 10Mortality

Figure 11Survival

Adjusted for number of diseases.

Figure 12ED presentations

Figure 13ED presentations

Figure 14Hospital admissions

Figure 15Hospital admissions

Figure 16Hospital admissions

Figure 17GP visits

Figure 18Adverse events

C.4. Clinical pharmacist based within a community clinic

Figure 19Mortality

Figure 20ED presentations

Figure 21Hospital admissions

Figure 22GP visits

Figure 23Total hospitalisations

C.5. Clinical pharmacist at the patients’ homes

Figure 24Mortality

Figure 25Hospital admission

Adjusted for CMS risk score for hospitalisation, patient age, total number of medication, ability to use a telephone, and detection of medication-related problems during initial in-home assessment

Figure 26Hospital admission

Figure 27GP visits

C.6. Clinical pharmacist based within a GP practice

Figure 28Mortality

Figure 29Mortality

Adjusted for age, creatinine, grade of left ventricular systolic dysfunction, atrial fibrillation, respiratory disease, total number of medical treatments, and diuretic use.

Figure 30ED presentations

Figure 31ED presentations

Figure 32Hospital admissions

Figure 33Hospital admissions

Figure 34Hospital admissions