Pharmacist support

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 30Pharmacist support

30. Pharmacist support

30.1. Introduction

Increasing numbers of patients with multiple co-morbidities are being exposed to large numbers of medications designed to treat each of the conditions from which they may suffer. This, however, is associated with increasing numbers of drug interactions, difficulties with concordance and possible admissions or readmissions associated with drug errors or adverse effects. The introduction of clinical pharmacists has been designed to minimise these difficulties and, in particular, medicines reconciliation has been conducted for many patients to ensure clarity of the drugs prescribed and taken. The presence of a ward based pharmacist is common practice in the UK. However, the precise input required from pharmacy support is still not clear and this question is posed in an attempt to understand the best way in which pharmacy support is used.

30.2. Review question: Do ward-based pharmacists improve outcomes in patients admitted to hospital with a suspected or confirmed acute medical emergency?

For full details see review protocol in Appendix A.

Table 1

PICO characteristics of review question.

30.3. Clinical evidence

Eighteen studies (20 papers) were included in the review;¹^,³^,⁸^,¹³^,¹⁵^,¹⁷^,¹⁸^,²¹^,³¹^,³⁵^,³⁷^,³⁹^,⁴⁴^,⁴⁶^,⁵⁷^–⁵⁹^,⁶²^,⁶⁹^,⁶⁹^,⁷⁰^,⁷⁰ these were split into 3 strata: regular in-hospital pharmacy support (where the ward-based pharmacist intervention included in-patient monitoring, and typically an admission and discharge service), pharmacist at admission, and pharmacist at discharge. These are summarised respectively in Table 2, Table 3 and Table 4 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 5 to Table 7). See also the study selection flow chart in Appendix B, study evidence tables in Appendix D, forest plots in Appendix C, GRADE tables in Appendix F and excluded studies list in Appendix G.

Table 2

Summary of studies included in the review (regular in-hospital pharmacy support).

Table 3

Summary of studies included in the review (pharmacist at admission).

Table 4

Summary of studies included in the review (pharmacist at discharge).

Table 5

Clinical evidence summary: Regular in-hospital ward based pharmacy support compared to no ward-based pharmacist.

Table 7

Clinical evidence summary: Pharmacist at discharge compared to no ward-based pharmacist.

Outcomes as reported in studies (not analysable):

Length of stay: intervention group had on average a 0.3-day shorter stay.
Readmission: intervention group had a 44% reduced readmission rate.

Table 6

Clinical evidence summary: Pharmacist at admission compared to no ward-based pharmacist.

Outcomes reported that were not analysable

The study by Khalil 2016³¹ reported the total number of medication errors:

Intervention: 29/56.
Control: 238/54.

30.4. Economic evidence

Published literature

Seven economic evaluations were identified with the relevant comparison and have been included in this review.¹³^,¹⁹^–²¹^,²⁹^,³²^,⁶⁶ Similar to the clinical evidence, these were split into 3 strata: regular ward-based pharmacist support (where the ward-based pharmacist intervention included in-patient monitoring, and typically an admission and discharge service) (n=5), pharmacist at admission (n=1), and pharmacist at discharge (n=1). The studies are summarised in the economic evidence profiles below (Table 8, Table 9 and Table 10) and the economic evidence tables in Appendix F.

Table 8

Economic evidence profile: regular ward-based pharmacist support versus no ward-based pharmacist.

Table 9

Economic evidence profile: Pharmacist support at admission versus no ward-based pharmacist.

Table 10

Economic evidence profile: Pharmacist support at discharge versus no ward-based pharmacist.

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

30.5. Evidence statements

Clinical

Stratum - Regular in-hospital ward based pharmacy support

Eight randomised controlled trials comprising 2,303 people evaluated the role of regular in-hospital pharmacist support for improving outcomes in secondary care, in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that regular in-hospital pharmacist support may provide a benefit for reduced mortality (3 studies, very low quality), reduced preventable adverse drug events in hospital (2 studies, very low quality) and at 90 days follow up (1 study, very low quality) and length of stay (2 studies, moderate quality) and increased patient and/or carer satisfaction at discharge and at one month follow-up (1 study, low quality). The evidence suggested that regular in-hospital pharmacist support has no effect on readmission (1 study, very low quality), adverse drug events at 3 to 6 months post discharge (1 study, very low quality) and admission (4 studies, moderate quality). Evidence suggested no difference between the groups for the outcome of reducing prescribing errors at discharge (2 studies, low quality) ; however there were increased prescribing errors at 30 days in regular in-hospital pharmacist support group compared to no pharmacist support group (1 study quality, moderate quality).

Stratum - Pharmacist at admission

Six randomised controlled trials comprising 401 people evaluated the role of pharmacists at admission for improving outcomes in secondary care, in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that pharmacists at admission may provide benefit for reduced medicine errors (2 studies, low quality), total medication errors within 24 hours of admission (1 study, moderate quality) and physician agreement (1 study, very low quality). However, there was no difference for quality of life (1 study, low quality), length of stay (1 study, moderate quality), or future hospital admissions (1 study, low quality) and a possible increase in mortality at 3 months (1 study, very low quality).

Stratum - Pharmacist at discharge

Four randomised controlled trials comprising 770 people evaluated the role of pharmacists at discharge for improving outcomes in secondary care, in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that pharmacists at discharge may provide a benefit for reduced prescription errors (1 study, low quality), reduced readmissions up to 22 days post discharge (1 study, very low quality) and reducing prescriber errors (drug therapy inconsistencies and omissions) at discharge (1 study, moderate quality). The evidence suggested that pharmacists at discharge have no effect on quality of life scales (1 study, very low to low quality).

Economic

Stratum - Regular ward-based pharmacist support

Three economic evaluations reported that the ward-based pharmacist intervention was dominant (more effective and less costly) compared to usual care. One of these economic evaluations was a cost-utility analysis reporting a QALY gain of 0.005. These analyses were assessed as partially applicable with potentially serious limitations.
One cost-utility analysis showed that the ward-based pharmacist intervention was cost-effective with an ICER of £632 per QALY gained (as calculated by the NGC). The analysis was assessed as partially applicable with potentially serious limitations.
One economic evaluation showed that regular ward-based pharmacist support was less effective and less costly, with no clear conclusion regarding cost effectiveness given the absence of a cost-effectiveness threshold for the reported outcomes. The analysis was assessed as partially applicable with potentially serious limitations.

Stratum – pharmacist at admission

One comparative cost analysis showed that pharmacist support at admission was cost saving compared to usual care. The analysis was assessed as partially applicable with potentially serious limitations.

Stratum – pharmacist at discharge

One cost-utility analysis showed that the ward-based pharmacist support at discharge was not cost effective, with an ICER of £327,378 per adjusted QALY gained. The analysis was assessed as partially applicable with minor limitations.

30.6. Recommendations and link to evidence

Recommendations	17. Include ward-based pharmacists in the multidisciplinary care of people admitted to hospital with a medical emergency.^a
Research recommendation	-
Relative values of different outcomes	Mortality, avoidable adverse events, quality of life, patient and/or carer satisfaction, length of stay in hospital, prescribing errors, missed medications, and medicines reconciliation were considered by the guideline committee to be critical outcomes. Readmissions, admissions to hospital, discharge from hospital and staff satisfaction were considered by the committee to be important outcomes.
Trade-off between clinical benefits and harms	A total of 18 studies (20 papers) were identified that assessed ward based pharmacist support. They were split into three categories: Regular in-hospital ward based pharmacy support compared to no ward-based pharmacist Eight randomised controlled trials were identified. The evidence suggested that regular in-hospital pharmacist support may provide benefit for reduced mortality, reduced preventable adverse drug events in hospital and at 90 days, length of stay and increased patient and/or carer satisfaction. However, there was no effect on readmission, adverse drug events at 3 to 6 months post discharge and admission. Evidence for the outcome prescribing errors at discharge suggested no difference between the groups for the outcome of reducing prescribing errors at discharge; however there were increased prescribing errors at 30 days in regular in-hospital pharmacist support group compared to no pharmacist support group. No evidence was found for quality of life, missed medications, medicines reconciliation, admissions to hospital, discharges or staff satisfaction. Pharmacist at admission compared to no ward-based pharmacist Six randomised controlled trials were identified. The evidence suggested that pharmacists at admission may provide benefit by reduced medicine errors, total medication errors within 24 hours of admission and physicians agreement. However, there was no difference for quality of life, length of stay, or future hospital admissions and a possible increase in mortality at 3 months. However, the mortality outcome was graded very low quality and the committee interpreted this with caution as it was from 1 small study with low events and wide confidence intervals. No evidence was found for avoidable adverse events, patient and/or carer satisfaction, readmissions, prescribing errors, missed medications or discharges. Pharmacist at discharge compared to no ward-based pharmacist Four randomised controlled trials were identified. The evidence suggested that pharmacists at discharge may provide benefit for reduced prescription errors, reduced readmissions up to 22 days post discharge and prescriber errors (drug therapy inconsistencies and omissions) at discharge. The evidence suggested that pharmacists at discharge have no effect on quality of life scales. No evidence was found for mortality, patient or staff satisfaction, length of stay, future hospital admissions, missed medications, avoidable adverse events or discharges. Summary Overall the evidence demonstrated some potential benefits for ward-based pharmacists supplementing the prescribing and drug delivery activities provided by physicians and nurses. The mechanism by which pharmacists might improve patient outcomes would most likely be through minimising prescribing errors and drug interactions, by ensuring appropriate prescribing or discontinuation of drugs. Pharmacist education and support is likely to improve patient and/or carer satisfaction. Evidence was found for these outcomes, though not in all populations and with some inconsistencies. No evidence was found relating to 7 day provision of a ward pharmacist. The committee decided to make a strong recommendation for ward based pharmacists because there was evidence of benefit in many of the facets of pharmacists’ work even though overall the evidence was relatively weak. The economic evidence was also in favour of the provision of pharmacy support. In addition, the presence of a ward based pharmacist is common practice in the UK and the experience of the committee was positive overall. The committee noted that studies involving the pharmacist at hospital discharge may have reduced the need for junior doctors to explain prescribing regimens, and the need for the patient to visit their general practitioner following discharge for drug review, which may have improved patient and/or carer satisfaction and which would have had a potential cost benefit. The committee also discussed the added value of having a pharmacist as part of daily MDTs (see Chapter 29 on MDTs). Prescription and administration errors are amongst the most commonly identified adverse events during a patient’s stay in hospital. Pharmacists as part of the MDT can reduce these errors and ensure that the patient gets the correct treatment in a time effective manner, as well as discontinuing drugs which are no longer required. The pharmacist has an important educational role which will be likely to improve patients’ compliance after discharge. These activities allow doctors to prioritise other tasks.
Trade-off between net effects and costs	Regular in-hospital pharmacy support compared to no ward-based pharmacist Five economic evaluations were identified. - Three economic evaluations reported that the ward-based pharmacist intervention was dominant (more effective and less costly) compared to usual care. - One UK cost-utility analysis showed that the ward-based pharmacist intervention was cost-effective with an ICER of £632 per QALY gained (as calculated by the NGC). - One economic evaluation showed that pharmacist support was less effective and less costly, with no clear conclusion regarding cost effectiveness given the absence of a cost-effectiveness threshold for the reported outcomes. Pharmacist at admission compared to no ward-based pharmacist One UK comparative cost analysis, which showed that the ward-based pharmacist intervention was cost saving compared to usual care. Pharmacist at discharge compared to no ward-based pharmacist One cost-utility analysis showed that the ward-based pharmacist intervention was not cost effective, with an ICER of £327,378 per adjusted QALY gained. There was a suggestion that the lack of seniority of the pharmacists and lack of integration in the ward team reduced the effectiveness in that study. The committee noted that clinical pharmacists in the UK studies were generally experienced (band 7/8) and have specialist knowledge in the medications they managed. This may not be the same profile in all the other non-UK studies. Additionally, standard care/control arm in the included studies was not always clearly defined and was variable in terms of clinical pharmacist input. Some studies included a specified level of clinical pharmacist input in the control group which was enhanced in the intervention group (for example, by attendance at ward rounds) while others described the introduction of a de-novo service. With the exception of the UK modelling study (Karnon 2008²⁹); all studies had a follow-up of 12 months or less and hence would not have assessed the long term impact of the ward based pharmacist intervention. Additionally, the majority of the studies assessed a limited number of cost categories; focusing on medication costs, pharmacist time and less on other staff time and patient-related downstream costs. The committee felt there was evidence that pharmacist support throughout the stay would achieve saving in terms of medications costs, which was the most frequently assessed cost category in the included studies. One study found the pharmacist cost was completely offset by medication cost savings. The evidence was less clear in terms of impact on other staff time as well as the impact on long-term patient outcomes, which were not always assessed in the included studies. However, in those studies that assessed impact on other staff time and long-term outcomes, the results showed potential for cost saving that could be extrapolated to the other studies. Avoiding medication errors and litigation costs was raised by the committee as another potential positive outcome. Overall, the committee felt that this could be a cost saving intervention. Overall, the committee concluded that the use of ward-based pharmacists throughout the hospital stay is cost-effective. Pharmacist support only at discharge was shown to be not cost effective but the evidence was limited.
Quality of evidence	The evidence reviewed for in-hospital pharmacist support was of very low to moderate quality due to risk of bias, imprecision and inconsistency. The evidence reviewed for pharmacist at admission was of very low to moderate quality due to risk of bias, imprecision and outcome indirectness. The outcome ‘agreement with prescriber’ which was used as a surrogate outcome for staff satisfaction was considered an indirect outcome. The evidence for pharmacist at discharge was of very low to moderate quality due to risk of bias and imprecision. The committee noted the improved benefits shown in the UK studies compared to other countries and felt this was due to the fact that ward-based pharmacists are already well embedded in UK practice. However, the committee did note that these studies did not report the level of pharmacist experience and this may limit the interpretation of benefit. The health economic evidence was assessed to be partially applicable (with only 1 study from the UK and only 1 reporting QALYs). The evidence was also considered to have potentially serious limitations with none of the studies being based on a review of the evidence base and the cost components included being variable.
Other considerations	There was no evidence specifically to support 7 day provision of ward based pharmacists. The committee therefore chose a general recommendation, recognising that pharmacy services would need to be scaled up in parallel with other services in the transition to a 7 day service. Currently medical wards in the UK do have access to a pharmacist. However, the pharmacist may be responsible for covering several areas concurrently; limiting the level of detail they can bring to medicines reconciliation and patient and staff communication. This is particularly important for an ageing population with multiple co-morbidities for whom polypharmacy adds complexity and may indeed be the cause of the acute admission. In this situation the pharmacist plays a vital role advising the medical team regarding the interactions of drugs and how to prescribe treatment optimally. Pharmacists are gradually acquiring independent prescribing rights. This allows them (following consultation with the prescribing doctor) to correct prescribing errors or make changes to better agents, relieving doctors of this task. Prescribing drugs to take home at the end of a person’s hospital stay could also facilitate earlier discharge from hospital and allow junior doctors to focus on other tasks such as the ward rounds. Assessment of the cost-effectiveness of prescribing pharmacists in hospital should include these considerations.

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Appendices

Appendix A. Review protocols

Table 11Review protocol: Pharmacist support

Review question	Do ward-based pharmacists improve outcomes in patients admitted to hospital with a suspected or confirmed acute medical emergency?
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 and young people (16 years and over) admitted to hospital with 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)	Presence of medical ward based pharmacists for 7 days a week for less than 7 days a week No ward based pharmacists
Outcomes	- Mortality during the study period (Dichotomous) CRITICAL - Avoidable adverse events during the study period (Dichotomous) CRITICAL - Quality of life during the study period (Continuous) CRITICAL - Patient and/or carer satisfaction during the study period (Continuous) CRITICAL - Length of stay in hospital during the study period (Continuous) CRITICAL - Readmissions within 30 days (Dichotomous) IMPORTANT - Future admissions to hospital (over 30 days) (Dichotomous) IMPORTANT - Discharges during the study period (Dichotomous) IMPORTANT - Prescribing errors during the study period (Dichotomous) CRITICAL - Missed medications during the study period (Dichotomous) CRITICAL - Medicines reconciliation during the study period (Dichotomous) CRITICAL - Staff satisfaction during the study period (Continuous) IMPORTANT
Study design	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Unit of randomisation	Patient Hospital Ward
Crossover study	Not permitted
Minimum duration of study	Not defined
Subgroup analyses if there is heterogeneity	- Frail elderly (Frail elderly; No frail elderly); Effects may be different in this subgroup - Haematology or oncology patients (Haematology or oncology patients; Not haematology or oncology patients); Effects may be different in this subgroup
Search criteria	Databases: Medline, Embase, the Cochrane Library Date limits for search: No date limits Language: English

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of pharmacy support

Appendix C. Forest plots

C.1. Regular in-hospital pharmacist support

Figure 2Mortality

Figure 3Survival

Figure 4Admission to hospital

Figure 5Readmission (up to 30 days)

Figure 6Prescribing errors (at discharge)

Figure 7Prescribing errors (30 day)

Figure 8Preventable adverse drug events (in-hospital)

Figure 9Preventable adverse drug events (90 day)

Figure 10Adverse drug reactions (6 months)

Figure 11Length of stay

Figure 12Patient satisfaction

Figure 13Patient and/or carer satisfaction

C.2. Pharmacist at admission

Figure 14Medication errors identified

Figure 15Quality of life

Figure 16Length of stay

Figure 17Admission

Figure 18Mortality

Figure 19Physician agreement

Figure 20Length of stay in acute admission unit (minutes)

Figure 21Total medication errors within 24 hours of admission

C.3. Pharmacist at discharge

Figure 22Quality of life (Global health)

Figure 23Quality of life (EQ-5D)

Figure 24Quality of life (EQ-VAS)

Figure 25Prescription errors

Figure 26Readmission (15-22 days)

Figure 27Prescriber errors (drug therapy inconsistencies and omissions) (at discharge)

Appendix D. Clinical evidence tables

Download PDF (781K)

Appendix E. Economic evidence tables

Appendix F. GRADE tables

Table 12Clinical evidence profile: Regular in-hospital pharmacy support versus no ward-based pharmacist

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Regular in-hospital pharmacist support	No ward-based pharmacist	Relative (95% CI)	Absolute	Quality	Importance
Mortality (follow-up median 1 years)
3	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	serious²	none	105/534 (19.7%)	19.8%	RR 0.92 (0.72 to 1.16)	16 fewer per 1000 (from 55 fewer to 32 more)	⨁◯◯◯ VERY LOW	CRITICAL
Survival (follow-up 1 years)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	very serious²	none	0/182 (0%)	0%	HR 0.94 (0.65 to 1.36)	-	⨁◯◯◯ VERY LOW	CRITICAL
Admissions to hospital (over 30 days) (follow-up median 1 years)
4	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	327/942 (34.7%)	38.4%	RR 0.93 (0.83 to 1.04)	27 fewer per 1000 (from 65 fewer to 15 more)	⨁⨁⨁◯ MODERATE	IMPORTANT
Readmission (follow-up 30 days)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	very serious²	none	40/298 (13.4%)	14.6%	RR 0.92 (0.62 to 1.37)	12 fewer per 1000 (from 55 fewer to 54 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Prescribing errors (follow-up at discharge; measured with: medication appropriateness index; Better indicated by lower values)
2	randomised trials	serious¹	serious inconsistency³	no serious indirectness	no serious imprecision	none	408	403	-	MD 0.02 lower (0.12 lower to 1.08 higher)	⨁⨁◯◯ LOW	CRITICAL
Prescribing errors (follow-up 30 days; measured with: medication appropriateness index; Better indicated by lower values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	304	309	-	MD 2.1 higher (0.45 to 3.75 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Preventable adverse drug events (follow-up until discharge)
2	randomised trials	very serious¹	serious³	no serious indirectness	very serious²	none	5/391 (1.3%)	5.4%	RR 0.74 (0.06 to 8.57)	14 fewer per 1000 (from 51 fewer to 409 more)	⨁◯◯◯ VERY LOW	CRITICAL
Preventable adverse drug events (follow-up 90 days)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	very serious²	none	7/295 (2.4%)	3.1%	RR 0.77 (0.29 to 2.05)	7 fewer per 1000 (from 22 fewer to 33 more)	⨁◯◯◯ VERY LOW	CRITICAL
Adverse drug reactions (follow-up 6 months)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	very serious²	none	3/43 (7%)	4.8%	RR 1.47 (0.26 to 8.33)	23 more per 1000 (from 36 fewer to 352 more)	⨁◯◯◯ VERY LOW	CRITICAL
Length of stay (days) (follow-up in-hospital; Better indicated by lower values)
2	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	547	569	-	MD 1.74 lower (2.76 to 0.72 lower)	⨁⨁⨁◯ MODERATE	CRITICAL
Patient and/or carer satisfaction (follow-up 1 months)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	71/89 (79.8%)	44.6%	RR 1.79 (1.38 to 2.32)	352 more per 1000 (from 169 more to 589 more)	⨁⨁◯◯ LOW	CRITICAL
Patient and/or carer satisfaction (at discharge)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	35/43 (81.4%)	54.8%	RR 1.49 (1.09 to 2.03)	269 more per 1000 (from 49 more to 564 more)	⨁⨁◯◯ LOW	CRITICAL

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.
3: Downgraded by 1 because: The point estimate varies widely across studies

Table 13Clinical evidence profile: Pharmacist at admission versus no ward-based pharmacist

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Pharmacist at admission	No ward-based pharmacist	Relative (95% CI)	Absolute	Quality	Importance
Medication reconciliation (measured with: errors identified at admission; Better indicated by lower values)
2	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	149	144	-	MD 0.36 higher (0.07 to 0.65 higher)	⨁⨁◯◯ LOW	CRITICAL
Quality of life (follow-up 3 months; measured with: EQ-VAS index; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	33	30	-	MD 6.2 higher (5.7 lower to 18.1 higher)	⨁⨁◯◯ LOW	CRITICAL
Length of stay (follow-up in-hospital; Better indicated by lower values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	50	49	-	MD 1.3 higher (108.96 lower to 111.56 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Admission (follow-up 3 months; Better indicated by lower values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	50	49	-	MD 0.1 lower (0.38 lower to 0.18 higher)	⨁⨁◯◯ LOW	IMPORTANT
Mortality (follow-up 3 months)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	very serious²	none	8/50 (16%)	10.2%	RR 1.57 (0.55 to 4.46)	58 more per 1000 (from 46 fewer to 353 more)	⨁◯◯◯ VERY LOW	CRITICAL
Staff satisfaction (follow-up at admission; assessed with: Physician agreement)
1	randomised trials	serious¹	no serious inconsistency	serious³	serious²	none	139/235 (59.1%)	43.7%	RR 1.35 (1.13 to 1.63)	153 more per 1000 (from 57 more to 275 more)	⨁◯◯◯ VERY LOW	IMPORTANT
Length of stay in AAU (minutes) (Better indicated by lower values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	216	232	-	3.2 higher (26.49 lower to 32.89 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Total medication errors within 24 hours of admission (Better indicated by lower values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	15/408 (3.7%)	0%	RR 0.05 (0.03 to 0.08)	748 fewer per 1000 (from 772 fewer to 763 fewer)	⨁⨁⨁◯ MODERATE	CRITICAL

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.
3: The majority of the evidence had indirect outcomes.

Table 14Clinical evidence profile: Pharmacist at discharge versus no ward-based pharmacist

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Pharmacist at discharge	No ward-based pharmacist	Relative (95% CI)	Absolute	Quality	Importance
Prescription errors (follow-up 6 weeks; assessed with: identification at outpatient follow-up)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	serious²	none	16/41 (39%)	68.2%	RR 0.57 (0.37 to 0.88)	293 fewer per 1000 (from 82 fewer to 430 fewer)	⨁◯◯◯ VERY LOW	CRITICAL
Quality of life (follow-up 6 months; measured with: Global health index; Better indicated by higher values)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	serious²	none	95	109	-	MD 0.23 higher (0.02 lower to 0.48 higher)	⨁◯◯◯ VERY LOW	CRITICAL
Quality of life (follow-up 6 months; measured with: Summated EQ-5D index; Better indicated by higher values)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	95	109	-	MD 0.05 higher (0.05 lower to 0.15 higher)	⨁⨁◯◯ LOW	CRITICAL
Quality of life (follow-up 6 months; measured with: EQ-VAS index; range of scores: 0-100; Better indicated by higher values)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	95	109	-	MD 2.8 higher (1.83 lower to 7.43 higher)	⨁⨁◯◯ LOW	CRITICAL
Readmission (follow-up 15-22 days)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	5/43 (11.6%)	32.5%	RR 0.36 (0.14 to 0.91)	208 fewer per 1000 (from 29 fewer to 279 fewer)	⨁⨁◯◯ LOW	IMPORTANT
Prescriber errors (Drug therapy inconsistencies and omissions) (follow-up at discharge)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	none	1/28 (3.6%)	56.3%	RR 0.06 (0.01 to 0.44)	529 fewer per 1000 (from 315 fewer to 557 fewer)	⨁⨁⨁◯ MODERATE	CRITICAL

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Appendix G. Excluded clinical studies

Table 15Studies excluded from the clinical review

Study	Exclusion reason
Abu-oliem 2013²	Inappropriate comparison (ward-based pharmacist)
Alassaad 2014⁴	Incorrect comparison. Post-hoc subgroup analysis for no of prescribed drugs from included study (Gillespie 2009²¹)
Basger 2015⁵	Incorrect population (patients admitted for treatment of chronic disease in addition to rehab after joint replacement surgery)
Bessen 2015⁷	Inappropriate study design (comparison of 2 hospitals)
Bolas 2004⁹	No extractable outcomes
Burnett 2009¹⁰	Inappropriate comparison (normal care involved chart reviews, counselling etc. by pharmacists)
Cani 2015¹¹	Not review population (chronic disease management)
Chen 2016¹²	Incorrect population (patients with chronic condition, not admitted to hospital); incorrect intervention (pharmacists were not ward-based)
De boer 2011¹⁴	Protocol only
Ghatnekar 2013A²⁰	Inappropriate study design (health economic model); no relevant outcomes
Graabaek 2013²²	Systematic review: study designs inappropriate (non-randomised studies, non-ward based interventions, ward-based comparators)
Heselmans 2015²³	Incorrect intervention (drug therapy changes communicated to the physician; pharmacist was not ward-based)
Hodgkinson 2006²⁴	Systematic review: study designs inappropriate (non-randomised studies, non-ward based interventions, ward-based comparators)
Horn 2006²⁵	No intervention (literature review)
Israel 2013²⁶	No relevant outcomes (underutilization of cardiovascular medications)
Jarab 2012²⁷	Study to be considered in the comm pharm review
Kaboli 2006²⁸	Systematic review: study designs inappropriate (non-randomised studies, non-ward based interventions, ward-based comparators)
Koehler 2009A³³	Inappropriate comparison- care bundle including clinical pharmacist for elderly high risk patients compared to usual care group including staff pharmacist
Klopotowska 2010³²	Incorrect study design (before and after)
Kucukarslan 2013³⁴	Incorrect study design (before and after)
Leape 1999³⁶	Incorrect study design (observational)
Lipton 1992³⁸	Incorrect interventions (post-discharge care)
Maclaren 2009⁴⁰	Incorrect study design (retrospective cohort)
Makowsky 2009⁴¹	Inappropriate comparison (ward-based pharmacist)
Malone 2001⁴²	Not review population (ambulatory care)
Mousavi 2013⁴³	Not review population (nutritional support service)
Neto 2011⁴⁵	Incorrect interventions (not ward-based)
O’dell 2005⁴⁷	Incorrect study design (non-randomised, observational)
Okumura 2014⁴⁹	Systematic review has unclear PICO (no breakdown of studies, most took place in ambulatory care)
O’Sullivan 2016⁴⁸	Inappropriate comparison (pharmacist review vs. clinical decision support software supported pharmacist review)
Penm 2014⁵¹	Systematic review (studies based in China only; references screened)
Phatak 2016⁵²	Inappropriate comparison (normal care involved daily pharmacist assessment)
Renaudin 2016⁵³	Systematic review and meta-analysis- ordered relevant references
Roblek 2016⁵⁴	Incorrect intervention (advice about drug-drug interactions given to physicians; pharmacist was not ward-based)
Sadik 2005⁵⁵	Study to be considered in the comm pharm review
Schnipper 2006⁵⁶	Study to be considered in the comm pharm review
Stowasser 2002⁶⁰	Incorrect interventions (not ward-based)
Suhaj 2016⁶¹	Incorrect population (patients with chronic condition, not admitted to hospital); incorrect intervention (pharmacists were not ward-based)
Upadhyay 2015⁶⁴	Incorrect population (patients with chronic condition, not admitted to hospital); incorrect intervention (pharmacists were not ward-based)
Upadhyay 2016⁶³	Incorrect population (patients with chronic condition, not admitted to hospital); incorrect intervention (pharmacists were not ward-based); no relevant outcomes
Viswanathan 2015⁶⁵	Systematic review is not relevant (outpatient settings only)
Wang 2015A⁶⁷	Incorrect population (patients with cancer, not admitted to hospital); incorrect intervention (pharmacists were not ward-based)
Zhao 2015E⁶⁸	Article not in English

Appendix H. Excluded economic studies

No studies were excluded.

Footnotes

(a): NICE’s guideline on medicines optimisation includes recommendations on medicines-related communication systems when patients move from one care setting to another, medicines reconciliation, clinical decision support, and medicines-related models of organisational and cross-sector working.

Bookshelf ID: NBK564916

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