Pharmacist support

National Guideline Centre (UK)

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

Table

Include ward-based pharmacists in the multidisciplinary care of people admitted to hospital with a medical emergency. Mortality, avoidable adverse events, quality of life, patient and/or carer satisfaction, length of stay in hospital, prescribing errors, (more...)

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Appendices

Appendix A. Review protocols

Table 11

Review protocol: Pharmacist support.

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

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Appendix E. Economic evidence tables

Appendix F. GRADE tables

Table 12

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

Table 13

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

Table 14

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

Appendix G. Excluded clinical studies

Table 15

Studies excluded from the clinical review.

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.

Publication Details

Copyright

Publisher

National Institute for Health and Care Excellence (NICE), London

NLM Citation

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.) Chapter 30, Pharmacist support.

Table 1PICO characteristics of review question

Population	Adults and young people (16 years and over) admitted to hospital with a suspected or confirmed AME
Interventions	Presence of medical ward based pharmacists for 7 days a week for less than 7 days a week
Comparison	No ward based pharmacists
Outcomes	Mortality (CRITICAL) Quality of life (CRITICAL) Patient and/or carer satisfaction (CRITICAL) Avoidable adverse events (CRITICAL) Length of stay in hospital (CRITICAL) Prescribing errors (CRITICAL) Missed medications (CRITICAL) Medicines reconciliation (CRITICAL) Readmissions up to 30 days (IMPORTANT) Future admissions to hospital (over 30 days) (IMPORTANT) Discharges (IMPORTANT) Staff satisfaction (IMPORTANT)
Study design	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.

Table 2Summary of studies included in the review (regular in-hospital pharmacy support)

Study

Intervention and comparison

Population

Outcomes

Comments

Claus 2014¹³

RCT

Pharmacist present on the ward. Duties included making active recommendations and performing patient follow-up.

Surgical ICU admissions (n=69) within a university hospital in Belgium.

Inclusion - over 16 years of age, length of stay greater than 48 hours.

Exclusion - none stated.

In-hospital mortality.

No pharmacist screening or discharge services.

Patients crossed to intervention group if the pharmacist was asked by the caregiver to give advice.

Pharmacist saw all patients, but recommendations were not passed onto the caregiver in the control group.

Intervention conducted by 1 of 2 clinical pharmacists.

Iowa Continuity of Care Study trial: Farris 2014¹⁸

(Farley 2014¹⁷)

RCT

Pharmacy case manager. Duties included medication reconciliation, ward visits and discharge service.

Versus

Nurse based medication reconciliation and discharge service.

General medicine, family medicine, cardiology or orthopaedic admissions (n=631) within an academic tertiary care hospital in the USA.

Inclusion - patients with certain disease classifications: hypertension, hyperlipidaemia, heart failure, coronary artery disease, myocardial infarction, stroke, transient ischemic attack, asthma, chronic obstructive pulmonary disease or receiving oral anticoagulation.

Preventable adverse drug events in-hospital; post-discharge (90 days) hospital

Readmission at 30 days; Admission at 90 days

Medication appropriatene ss index (MAI) at discharge; 30 days; 90 days.

Farley 2010 indicates that the initial medication reconciliation is normally undertaken by a nurse in the control group.

Unclear number of pharmacists involved.

Data was extracted from Farris 2014 MAI is based on 6 criteria.

Gillespie 2009²¹

RCT

Pharmacist present on the ward. Duties included taking part in the rounding team, documenting medication history, and discharge counselling.

Versus

No pharmacist involvement in the healthcare team at the ward level.

Patients (n=400) admitted to the 2 acute internal study wards at a University teaching hospital in Sweden.

Inclusion - 80 years of age.

Exclusion - previously been admitted to the study wards during the study period or had scheduled admissions.

Overall survival at 12 months, reported as hazard ratio.

Admission at 12 months

A follow-up telephone call to patients 2 months after discharge was conducted in the intervention group

Admission and discharge documentation filled by physicians and nurses in comparison group Intervention conducted by 1 of 3 clinical pharmacists.

During follow-up period intervention patients received enhanced care again, but were excluded if admitted during the intervention period.

Kucukarslan 2003³⁵

Quasi-RCT

Pharmacist present on the ward. Duties included taking part in the rounding team, documenting medication history, and discharge counselling.

Versus

Standard care from 1 pharmacist (implication in paper that this is not ward-based).

All patients (n=165) admitted to 1 of the 2 internal medicine study wards within a tertiary care hospital in the USA.

Inclusion - admitted to the internal medicine service and remained in the same patient care unit until discharge.

Exclusion – none given.

Avoidable adverse drug events until discharge.

Length of stay in-hospital (reported as mean difference).

Re-admission (unclear follow-up time, reported as percentage reduction).

Admitting process was based on the availability of beds and physician service.

Pharmacist on the ward Mon-Fri. Intervention conducted by 1 of 2 clinical pharmacists.

Usual care involved identification of medication problems retrospectively through records

Shen 2011⁵⁸

China

RCT

Clinical pharmacist part of the treating team – communicated any potentially inappropriate antibiotic use (indication, choice, dosage, dosing schedule, duration, conversion) with the physician to discuss and make recommendations.

Versus.

Standard treatment strategies performed by the physicians and nurses without pharmacist involvement.

n=354 inpatients in 2 respiratory wards diagnosed with respiratory tract infections.

Exclusion criteria: transferred from other medical departments; transferred to other medical departments for further treatment; already received antibiotics before admission; did not receive antibiotics during hospitalisation.

Length of stay.

Regular-in ward pharmacist support strata.

Scullin 2007⁵⁷

RCT

Pharmacist present on the ward. Duties included admission services, in-patient monitoring, and discharge services

Versus

Traditional clinical pharmacy services (no further details given).

Admitted patients (n=762) to the 4 medical study wards within 3 general hospitals in northern Ireland.

One of the following criteria: taking at least 4 regular medication, were taking a high risk drug(s), were taking antidepressants and were 65 years old or older, had a hospital admission within the last 6 months, prescribed antibiotics on day 1 of admission.

Exclusion - scheduled admissions and patients admitted from private nursing homes.

Admission at 12 months.

Mortality at 12 months.

Length of stay.

Intervention conducted by 1 of 4 clinical pharmacists/pharm acy technician pairs.

Spinewine 2007⁵⁹

RCT

Pharmacist present on the ward. Duties included taking part in the rounding team, documenting medication history, and discharge counselling.

Versus

Usual care (no details of any clinical pharmacist involvement).

All eligible patients (n=186) admitted to the Geriatric Evaluation and Management (GEM) unit within a university teaching hospital in Belgium.

GEM unit accepted patients over 70 years of age.

Rate of death at 1 year follow-up.

Satisfaction with information received.

Admission at 12 months.

Medical appropriateness index.

Pharmacist was on the unit for 4 days a week.

Intervention conducted by a single clinical pharmacist.

GEM team consisted of 2 geriatricians, 2 residents, nurses, 2 physiotherapists, a social worker, a psychologist, and an occupational therapist.

MAI is based on 10 criteria (not defined).

Zhao 2015⁷⁰ & Zhao 2015B⁶⁹

RCT

Interventions by clinical pharmacists including individual drug regimens, attending daily medical rounds, advice to physicians, education of medical staff, patient education on lifestyle changes, psychological interventions such as stress reduction, medication counselling at discharge, monthly follow up telephone calls post-discharge.

Versus

Conventional medical treatment without pharmacist participation.

n=90 patients admitted to the cardiology ward in a hospital in China.

Inclusion criteria: diagnosis of CHD by physician, accepted ≥4 kinds of drugs, ≥18 years, primary high school education, able to complete the study, available for telephone follow up.

Exclusion criteria: pregnant/lactating women, patients enrolled in other studies, severe co-morbidities, family history of psychosis, and barriers to communication.

Avoidable adverse events (adverse drug reactions).

Patient and/or carer satisfaction.

Table 3Summary of studies included in the review (pharmacist at admission)

Study

Intervention and comparison

Population

Outcomes

Comments

Aag 2014¹

RCT

Pharmacist medication reconciliation.

Versus

Nurse medication reconciliation.

Consecutively admitted patients (n=201) to the Cardiology study ward at a University hospital in Norway.

Inclusion - aged 18 and over.

Exclusion - terminal illness, isolated due to an infectious disease, unable to communicate in either Norwegian or English.

Medication discrepancies identified at admission.

Prescribing physician agreement at admission.

Agreement with prescriber used as a surrogate outcome for staff satisfaction.

Both pharmacists and nurses were taught and trained by an independent, experience clinical pharmacist both theoretically and practically in order to perform medicine reconciliation.

Study involved 3 pharmacists and 3 nurses.

Khalil 2016³¹

Australia

RCT

Pharmacist-initiated medication reconciliation – pharmacist obtained a ‘best possible medication history’ from the patient and/or other sources, undertook admission medication reconciliation, reviewed current medications and the need for new medications in relation to the admission diagnosis, developed a medication management plan with the referring senior medical officer and charted on the electronic medication administration record

Versus

Usual care – medication orders charted by medical staff.

n=110 adult medical patients admitted to the acute assessment and admission (AAA) unit via the ED during pharmacy operating hours (8.30am – 5pm).

Exclusion criteria: not admitted to the AAA ward within 24 hours; no medications prior to admission; not a general medical patient.

Prescribing errors.

Pharmacist at admission strata.

Lind 2016³⁷

Denmark

RCT

Clinical pharmacist intervention - obtaining medication history (using a minimum of 2 sources, 1 of which was an interview with the patient and/or relatives where possible), entering prescriptions into the electronic medication module (EMM), medication reconciliation, reviewing overall medication treatment and writing a note in the electronic medical record.

Versus

Standard care – on arrival, patients triaged by a nurse, then seen by a physician who was responsible for obtaining medication history, reconciling and assessing medication treatment and entering prescriptions in the EMM.

n=448 patients arriving at the acute admission unit on weekdays 9am-4.15pm.

Inclusion criteria: ≥18 years, taking ≥4 drugs daily (including over-the-counter, herbals and supplements).

Exclusion criteria: terminal or intoxicated; assigned to triage level 1; referred to acute outpatient clinic; unable to give informed consent; interviewed by physician prior to giving informed consent; unexpected overnight stay.

Length of stay on the acute admission unit (defined as interval in minutes between arrival and discharge or transfer to a hospital ward).

Pharmacist at admission strata.

Lisby 2010³⁹

RCT

Pharmacist admission review.

Versus

Senior physician admission review.

Consecutively admitted patients (n=100) to acute internal medicine study ward within 1 regional hospital in Denmark.

Inclusion - patients were 70 years or older.

Self-experienced quality of health at 3 months.

Length of stay in hospital.

Admission rate at 3 months.

Mortality.

Unclear number of pharmacists involved.

Nester 2002⁴⁴

Quasi-RCT

Pharmacist medication reconciliation.

Versus

Nurse medication reconciliation.

Consecutively admitted patients (n=100) to a tertiary care referral centre in the USA.

Inclusion - over 18, responsive and able to speak English.

Exclusion - intensive care, ambulatory surgical and labour-and-delivery units.

Medication discrepancies identified at admission.

Nurses still performed medication history taking in the intervention group, but in all cases the intervention was conducted first.

Unclear number of pharmacists involved.

Allocation by alternation of consecutive admissions.

Tong 2016⁶²

Australia

RCT

Early medication review and charting on admission involving a partnership between a pharmacist and a medical officer – pharmacist took medical history, VTE risk assessment and discussed medical and medication problems with admitting medical officer to agree a medication management plan.

Versus

Standard medication charting by medical officers of relevant teams, with subsequent medication reconciliation performed by pharmacist within 24 hours of admission.

n=881 patients admitted to the general medical unit (GMU) and emergency short stay unit (ESSU) during pharmacist working hours (7am-9pm).

Exclusion criteria: medication chart written by a doctor before pharmacist review; admitted to ESSU and not reviewed by a pharmacist.

Prescribing errors. (

Pharmacist at admission strata.

Table 4Summary of studies included in the review (pharmacist at discharge)

Study

Intervention and comparison

Population

Outcomes

Comments

Al-Rashed 2002³

RCT

Pre-discharge counselling (24 hours before discharge) by the clinical pharmacist attached to that ward.

Versus

Normal hospital discharge policy – all patients, their GPs, district nurses and carers received a copy of the patient’s medication and information discharge summary sheet (MIDS) and patients received a medicine reminder card. Nurse went through (MIDS) with patients.

n=83 patients admitted to 2 care of the elderly wards (UK).

Inclusion criteria: >65 years, prescribed 4 or more regular items, were to be discharged to their own home and had an abbreviated mental score >7/10, English as a first language, and routine clinical pharmacist assessment that they could have problems with their medicines after discharge.

Readmission.

Bladh 2011⁸

RCT

Pharmacist discharge review

Versus

Usual care, which was received from the same group of physicians and nurses. No other details given.

Patients (n=345) admitted on weekdays to the 2 internal medicine study wards at a university hospital in Sweden.

Inclusion - capable of assessing their HRQL and giving written informed consent.

Exclusion - poor Swedish language, planned discharge before intervention can be performed, transferred during their stay to other hospitals or wards not belonging to the Department of Medicine.

EQ-5D summarised index at 6 months follow-up.

Pharmacist not ward based (no patient contact) until discussion at discharge however, pharmacist performed “continuous medication reviews” from medical records compared with usual care where there was no “continuous medication review”.

Same physicians and nurses undertook care for the intervention and control.

Intervention carried out by 1 of 3 pharmacists.

Eggink 2010¹⁵

RCT

Pharmacist discharge review.

Versus

Nurse discharge review.

Patients (n=89) to be discharged (no criteria given) in the Cardiology study ward within a teaching hospital in the Netherlands.

Inclusion - patients have prescribed 5 or more medicines (from any class) at discharge.

Exclusion - none stated.

Prescription errors identified during first outpatient follow-up.

Unclear number of pharmacists involved.

Nickerson 2005⁴⁶

RCT

Seamless care pharmacist at discharge including medication reconciliation, review of drug regime as part of comprehensive pharmaceutical care work-up, identification of problems and communication to community pharmacy, hospital staff and family physician, medication discharge counselling and a medication compliance chart

Versus

Standard care at discharge - discharge counselling and manual transcription of discharge notes from medical chart by nurse.

n=253 patients admitted to 2 family practice units (Canada).

Inclusion criteria: not discharged to another hospital, prescribed at least 1 medication at discharge, provided consent, agreement from community pharmacy, no previous study enrolment.

Exclusion criteria: unable to answer study questions, unavailable for follow-up.

Prescriber errors-unresolved drug therapy inconsistencies and omissions.

Table 5Clinical evidence summary: Regular in-hospital ward based pharmacy support compared to no ward-based pharmacist

Outcomes	No of Participants (studies) Follow up	Quality of the evidence (GRADE)	Relative effect (95% CI)	Anticipated absolute effects
Outcomes	No of Participants (studies) Follow up	Quality of the evidence (GRADE)	Relative effect (95% CI)	Risk with no ward-based pharmacist	Risk difference with Regular in-hospital pharmacist support (95% CI)
Mortality	1060 (3 studies) 1 years	⊕⊝⊝⊝ VERY LOW^a^,^b due to risk of bias, imprecision	RR 0.92 (0.72 to 1.16)	198 per 1000	16 fewer per 1000 (from 55 fewer to 32 more)
Survival	368 (1 study) 1 years	⊕⊝⊝⊝ VERY LOW^a^,^b due to risk of bias, imprecision	HR 0.94 (0.65 to 1.36)	Control group risk not provided	Absolute effect cannot be calculated
Future admissions to hospital (over 30 days)	1892 (4 studies) 1 years	⊕⊕⊕⊝ MODERATE^a due to risk of bias	RR 0.93 (0.83 to 1.04)	384 per 1000	27 fewer per 1000 (from 65 fewer to 15 more)
Readmission	592 (1 study) 30 days	⊕⊝⊝⊝ VERY LOW^a^,^b due to risk of bias, imprecision	RR 0.92 (0.62 to 1.37)	146 per 1000	12 fewer per 1000 (from 55 fewer to 54 more)
Prescribing errors medication appropriateness index	811 (2 studies) at discharge	⊕⊕⊕⊝ LOW^a^,^c due to risk of bias, inconsistency	-	-	The mean prescribing errors in the intervention groups was 0.02 lower (0.12 lower to 1.08 higher)
Prescribing errors medication appropriateness index	613 (1 study) 30 days	⊕⊕⊕⊝ MODERATE^a due to risk of bias	-	The mean prescribing errors in the control groups was 9.6	The mean prescribing errors in the intervention groups was 2.1 higher (0.45 to 3.75 higher)
Preventable adverse drug events	790 (2 studies) until discharge	⊕⊝⊝⊝ VERY LOW^a^,^b^,^c due to risk of bias, inconsistency, imprecision	RR 0.74 (0.06 to 8.57)	54 per 1000	14 fewer per 1000 (from 51 fewer to 409 more)
Preventable adverse drug events	588 (1 study) 90 days	⊕⊝⊝⊝ VERY LOW^a^,^b due to risk of bias, imprecision	RR 0.77 (0.29 to 2.05)	31 per 1000	7 fewer per 1000 (from 22 fewer to 33 more)
Adverse drug reactions	85 (1 study) 6 months	⊕⊝⊝⊝ VERY LOW^a^,^b due to risk of bias, imprecision	RR 1.47 (0.26 to 8.33)	48 per 1000	23 more per 1000 (from 36 fewer to 352 more)
Length of stay (days)	1116 (2 studies) in-hospital	⊕⊕⊕⊝ MODERATE^a due to risk of bias		The mean length of stay in the control groups was 17.8 days	The mean length of stay in the intervention groups was 1.74 lower (2.76 to 0.72 lower)
Patient and/or carer satisfaction (1 month follow-up)	172 (1 study) 1 months	⊕⊕⊝⊝ LOW^a due to risk of bias	RR 1.79 (1.38 to 2.32)	446 per 1000	352 more per 1000 (from 169 more to 589 more)
Patient and/or carer satisfaction (at discharge)	85 (1 study) at discharge	⊕⊕⊝⊝ LOW^a^,^b due to risk of bias, imprecision	RR 1.49 (1.09 to 2.03)	548 per 1000	269 more per 1000 (from 49 more to 564 more)

(a): 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.

(b): Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

(c): Downgraded by 1 because: The point estimate varies widely across studies, unexplained by subgroup analysis.

Table 6Clinical evidence summary: Pharmacist at admission compared to no ward-based pharmacist

Outcomes	No of Participants (studies) Follow up	Quality of the evidence (GRADE)	Relative effect (95% CI)	Anticipated absolute effects
Outcomes	No of Participants (studies) Follow up	Quality of the evidence (GRADE)	Relative effect (95% CI)	Risk with no ward-based pharmacist	Risk difference with pharmacist at admission (95% CI)
Medication errors identified at admission	293 (2 studies)	⊕⊕⊝⊝ LOW^a^,^b due to risk of bias, imprecision		The mean medication errors identified in the control groups was 1.51	The mean medication reconciliation in the intervention groups was 0.36 higher (0.07 to 0.65 higher)
Quality of life EQ-VAS index	63 (1 study) 3 months	⊕⊕⊝⊝ LOW^a^,^b due to risk of bias, imprecision		The mean quality of life in the control groups was 60.9	The mean quality of life in the intervention groups was 6.2 higher (5.7 lower to 18.1 higher)
Length of stay (hours)	99 (1 study) in-hospital	⊕⊕⊕⊝ MODERATE^a due to risk of bias		The mean length of stay in the control groups was 239.9 hours	The mean length of stay in the intervention groups was 1.3 higher (108.96 lower to 111.56 higher)
Admissions	99 (1 study) 3 months	⊕⊕⊝⊝ LOW^a^,^b due to risk of bias, imprecision		The mean admission in the control groups was 0.4 admissions per patient	The mean admission in the intervention groups was 0.1 lower (0.38 lower to 0.18 higher)
Mortality	99 (1 study) 3 months	⊕⊝⊝⊝ VERY LOW^a^,^b due to risk of bias, imprecision	RR 1.57 (0.55 to 4.46)	102 per 1000	58 more per 1000 (from 46 fewer to 353 more)
Physician agreement	457 (1 study) at admission	⊕⊝⊝⊝ VERY LOW^a^,^b^,^c due to risk of bias, indirectness, imprecision	RR 1.35 (1.13 to 1.63)	437 per 1000	153 more per 1000 (from 57 more to 275 more)
Length of stay in acute admissions unit (AAU) (minutes)	448 (1 study)	⊕⊕⊕⊝ MODERATE¹ due to risk of bias	-	The mean length of stay in the control groups was 339 minutes.	The mean length of stay in intervention group was 3.2 min higher (26.49 lower to 32.89 higher)
Total medication errors within 24 hours of admission	881 (1 study)	⊕⊕⊕⊝ MODERATE¹ due to risk of bias	RR 0.05 (0.03 to 0.08)	787 per 1000	748 fewer per 1000 (from 772 fewer to 763 fewer)

(a): 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.

(b): Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

(c): The majority of the evidence had indirect outcomes.

Table 7Clinical evidence summary: Pharmacist at discharge compared to no ward-based pharmacist

Outcomes

No of Participants (studies) Follow up

Quality of the evidence (GRADE)

Relative effect (95% CI)

Anticipated absolute effects

Risk with no ward-pharmacist

Risk difference with pharmacist at discharge (95% CI)

Quality of life

Global health index

204

(1 study)

6 months

⊕⊝⊝⊝

VERY LOW^a^,^b

due to risk of bias, imprecision

The mean quality of life in the control groups was

2.77

The mean quality of life in the intervention groups was

0.23 higher

(0.02 lower to 0.48 higher)

Quality of life

Summated EQ-5D index

204

(1 study)

6 months

⊕⊕⊝⊝

LOW^a

due to risk of bias

The mean quality of life in the control groups was

0.43

The mean quality of life in the intervention groups was

0.05 higher

(0.05 lower to 0.15 higher)

Quality of life

EQ-VAS index. Scale from: 0 to 100.

204

(1 study)

6 months

⊕⊕⊝⊝

LOW^a

due to risk of bias

The mean quality of life in the control groups was

56.3

The mean quality of life in the intervention groups was

2.8 higher

(1.83 lower to 7.43 higher)

Prescription errors identification at outpatient follow-up

(1 study)

6 weeks

⊕⊝⊝⊝

VERY LOW^a^,^b

due to risk of bias, imprecision

RR 0.57 (0.37 to 0.88)

682 per 1000

293 fewer per 1000

(from 82 fewer to 430 fewer)

Readmission

(1 study)

15-22 days

⊕⊕⊝⊝

LOW^a^,^b

due to risk of bias, imprecision

RR 0.36 (0.14 to 0.91)

325 per 1000

208 fewer per 1000

(from 29 fewer to 279 fewer)

Prescriber errors (drug therapy inconsistencies and omissions)

147

(1 study)

at discharge

⊕⊕⊕⊝

MODERATE^a

due to risk of bias

RR 0.06 (0.01 to 0.44)

563 per 1000

529 fewer per 1000

(from 315 fewer to 557 fewer)

(a): 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.

(b): Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Table 8Economic evidence profile: regular ward-based pharmacist support versus no ward-based pharmacist

Study	Applicability	Limitations	Other comments	Incremental cost	Incremental effects	Cost effectiveness	Uncertainty
Claus 2014¹³ [Belgium]	Partially applicable^a	Potentially serious limitations^b	Within trial analysis of individual patient level data Population: Critically ill patients (>16 years of age and with minimum length of ICU stay of 2 days) and in a 22-bed, surgical ICU at Ghent University Hospital, Belgium. Comparators: No clinical pharmacist direct involvement in patient care. A clinical pharmacist is directly involved in patient care Follow-up: ICU stay	2 versus 1: Saves £159	2 versus 1: 0.057 in-hospital deaths 0.07 adverse events	Pharmacist intervention less costly and less effective	Matched analysis: No significant difference in drug costs. Excluding liver transplantation and tracheostomy: difference in drug costs remained non-significant (p=0.78 and 0.88 respectively). Excluding outlier ICU drug costs (> 2SD): Difference in drug costs was significant after excluding patients with outlier drug costs (p<0.001) in the randomised analysis. In the matched analysis (comparing the matched before- and after-groups with the intervention 1), the difference in drug costs was significant (p<0.001 for both groups).
Ghatnekar 2013²⁰ [Sweden]	Partially applicable^c	Potentially serious limitations^d	Decision tree model Population: hospital inpatients Comparators: Standard care Multidisciplinary team including clinical pharmacist undertakes systematic medication review and reconciliation from admission to discharge (the Lund Integrated Medicines Management [LIMM]) Follow-up: 3 months	2 versus 1: Saves £280	2 versus 1: 0.005 QALYs gained	Pharmacist intervention dominant	Both the admission and discharge parts of the model showed that the LIMM model was dominant. The following sensitivity analyses were reported: - assuming no quality control of the discharge medication report - reduction in hospitalisation cost by 50% - hospitalisation cost 38% higher in intervention arm - admission part probability for hospitalisation in intervention arm increased to 100% - intervention cost (time) 50% higher - cost (time) for physicians and nurses administration reduced by 50% All SAs found the LIMM model to be dominant.
Gillespie 2009²¹ [Sweden]	Partially applicable^e	Potentially serious limitations^f	Within-trial analysis Population: Elderly inpatients (80 years or older) admitted to 2 acute internal medicine wards at a University Hospital of Uppsala, Sweden. Comparators: No pharmacist involvement in the healthcare team at the ward level. Pharmacist present on the ward. Follow-up: 12 months	2 versus 1: Saves £122	2 versus 1: 10 deaths averted per 1000	Pharmacist intervention dominant	None reported
Karnon 2008²⁹ [UK]	Partially applicable^g	Potentially serious limitations^h	Decision tree model Population: inpatients at 400 beds acute hospital (average hospital size) with around 14 wards Comparators: No ward-based pharmacist (a pharmacist covers 2 wards of about 30 patients over a morning to provide basic level of pharmaceutical care and in the afternoons they have departmental commitments) Ward-based senior pharmacist (grade 7/8a) attends rounds with residents, nurses, attending staff each morning; is present in the ward for consultation and assistance to nursing staff during the rest of the morning and is available on call as necessary during the rest of the day. Time horizon: 5 years	2 versus 1: £ 0.18 million per hospital over 5 years	2 versus 1: 285 QALYs gained per hospital over 5 years	Pharmacist intervention cost effective (ICER: £631.57 per QALY gained)	The analysis was run using the lower and upper estimates of the intervention cost, which were calculated assuming an average of 2.5 and 1.5 wards per morning per pharmacist in the intervention 1 scenario. The authors presented another analysis including the cost of treating pADEs only but not the monetary valuation of the health outcomes (QALYs), which showed that the ward-based pharmacist intervention had small expected negative NMB for the minimum and maximum intervention cost scenario.
Klopotowska 2010³² [Netherlands]	Partially applicableⁱ	Potentially serious limitations^j	Before and after comparative interventional study Population: patients in an adult surgical and medical 28-bed ICU of the academic Medical Centre Comparators: Standard pharmacy services provided by the hospital pharmacy department. Two experienced hospital pharmacists present on the ICU daily and attending multidisciplinary patient review meeting. Time horizon: ICU stay.	2 versus 1: Saves £108	2 versus 1: 0.38 less prescribing errors per patient 0.009 less prescribing errors that resulted in patient harm (pADEs) per patient 0.552 less potentially harmful pADEs per patient 0.263 less prescribing errors that did not result in harm per patient	Pharmacist intervention dominant	No sensitivity analysis reported Subgroup analysis: comparing first half of the intervention period (4 months) versus the second half showed significant difference in outcomes between the 2 periods, with the second period showing better outcomes

: Abbreviations: ICER: incremental cost-effectiveness ratio; ICU: intensive care unit; n/a: not applicable; pADE: preventable adverse events; QALY: quality-adjusted life years; RCT: randomised controlled trial; SD: standard deviation.

(a): QALYs were not used as an outcome measure and only costs and cost savings were included as outcomes. Some uncertainty regarding the applicability of resource use and costs from Belgium (2013) to current NHS context. The intervention is delivered by a junior and a senior clinical pharmacist; which may not be the same as in NHS hospitals.

(b): The study is a comparative cost analysis with no health outcomes. The costs included were only pharmacist time and ICU drug costs while the cost of hospital stay and other staff time were not included. The study follow-up is short (ICU stay) and may not capture the difference in all relevant costs. Limited sensitivity analysis is reported.

(c): The standard care arm in the study is not clearly described. Some uncertainty regarding the applicability of resource use and costs from Sweden (2009) to current NHS context. Changes in quality of life are based on the literature and assumptions and not reported directly from patients.

(d): The model has a short time horizon and does not capture differences in downstream costs and outcomes between the comparators. The baseline and relative treatment effectiveness estimates are based on a series of non-randomised studies conducted to evaluate the LIMM model and source the input parameters for the model, hence by definition, does not reflect all evidence in the area. Local costs appear to have been used and it is not clear whether these costs reflect national costs. A potential conflict of interest might exist given that the study is funded by a pharmacy company with commercial interest in disseminating the LIMM model.

(e): QALYs were not used as an outcome measure. Some uncertainty regarding the applicability of resource use and costs from Sweden (2008) to current NHS context. The intervention is delivered by pharmacists with postgraduate training in clinical pharmacy but no specialist status which may not reflect the situation in UK hospitals.

(f): Relative effectiveness evidence is based on a single RCT, so by definition does not reflect all evidence in the area. Follow-up for 12 months which may not capture all relevant costs and outcomes. Primary care visits, medication costs and cost of other staff time were not included in the analysis. No sensitivity analysis is reported.

(g): Some uncertainty regarding the applicability of resource use and costs from the literature, which were converted to 2006 UK pounds and adjusted for inflation. No discounting was applied despite using a 5-year time horizon. Utility decrements due to medication errors are based on estimates reached at through discussion within the research team and not based on data collected from patients.

(h): The model has a relatively short time horizon and may not capture all the relevant costs and outcomes, given the potential for preventing fatal medication errors. The health outcomes assessed included only QALY gains from prevention of medication errors. The authors reported that the estimates of baseline and relative effectiveness are “subjectively defined by the authors based on evidence from the literature and qualitative findings from an expert elicitation workshop involving mixture of human factors experts and health professionals to estimate individual error incidence and detection rates” however, no detail is given regarding how the evidence has been identified or reviewed. Costs relating to the time of other health care professionals, which might be affected by more pharmacist involvement, have not been included.

(i): QALYs were not used as an outcome measure and only costs and cost savings were included as outcomes. Some uncertainty regarding the applicability of resource use and costs from the Netherland (2007) to current NHS context. The intervention is delivered by senior clinical pharmacists but with limited ICU experience, which may not be the same as in NHS hospitals.

(j): The study is a cost-consequences analysis with only patient harm as a health outcome. The costs included were limited to staff time and potential saving from pADEs, while the cost of hospital stay and medication were not included. The study follow-up is short (ICU stay) and may not capture all relevant costs and outcomes. No sensitivity analysis is reported.

Table 9Economic evidence profile: Pharmacist support at admission versus no ward-based pharmacist

Study

Applicability

Limitations

Other comments

Incremental cost

Incremental effects

Cost effectiveness

Uncertainty

Fertleman 2005¹⁹

[UK]

Partially applicable^a

Potentially serious limitations^b

Before-and-after observational study
Population: medical patients admitted within the preceding 24 hours to a general medical ward at a district general hospital (Northwick Park hospital in north-west London)
Comparators:
- Ward-based pharmacist provide pharmaceutical care for 1-2 hours at some time during the day (usual care)
- Senior pharmacist present on post-admission (post-take) ward rounds (PTWR) in addition to the usual care
Follow-up: 3 days

2 versus 1:

Saves £142 in the increase in drug costs between admission and discharge

2 versus 1:

n/a

Pharmacist presence during ward round cost saving

None reported.

: Abbreviations: ICER: incremental cost-effectiveness ratio; ICU: intensive care unit; n/a: not applicable; pADE: preventable adverse events; QALY: quality-adjusted life years; RCT: randomised controlled trial; SD: standard deviation.

(a): QALYs were not used as an outcome measure. Some uncertainty regarding the applicability of resource use and costs from 2003 to current NHS context.

(b): Observational study with no adjustment for confounders, so by definition not reflecting all evidence in this area. The study has a very short follow-up time for both the pre- and post-intervention phases (3 ward rounds each) and the calculated cost-saving was extrapolated over a year. Long-term impact on costs and outcomes has not been assessed. Additionally, limited costs were included in the analysis (medication costs and pharmacist time). No sensitivity analysis is reported.

Table 10Economic evidence profile: Pharmacist support at discharge versus no ward-based pharmacist

Study

Applicability

Limitations

Other comments

Incremental cost

Incremental effects

Cost effectiveness

Uncertainty

Wallerstedt 2012⁶⁶

[Sweden]

Partially applicable^a

Minor limitations^b

Within-trial analysis (linked trial: Bladh 2011⁸
Population: Elderly inpatients on 2 internal medicine wards at Sahlgrenska University Hospital, Sweden.
Comparator:
- Usual care, which was received from the same group of physicians and nurses.
- Clinical pharmacists delivering a composite intervention consisting of medication review including feedback to physicians on prescribing, drug treatment discussion with the patient at discharge, medication report including summary of drug treatment changes to be sent to the GP
Follow-up: 6 months

2 versus 1:

£1,050

2 versus 1:

0.0035

Pharmacist intervention not cost effective with ICER £327,378 per adjusted QALY gained

Probability Intervention 2 cost-effective (£20K/30K threshold): NR/NR

Probability Intervention 2 cost-effective (£35,326 (50,000 Euro) threshold): 20%

Two sensitivity analyses were reported:

-: Subgroup of deceased (terminally ill) and alive patients

-: Missing data for EQ-5D were imputed using a regression model (multiple imputation)

-: Terminally ill patients:

ICER for deceased (terminally ill) patients-baseline-adjusted analysis: dominant (£56,946 saved per QALY gained)

95% CI: NR

ICER for alive patients-baseline-adjusted analysis: £125,856 per QALY gained

95% CI: NR

ICER for alive patients- unadjusted analysis: £179,748 per QALY gained

95% CI: NR

-: Imputed dataset:

ICER – using baseline-adjusted analysis: £81,377 per QALY gained.

95% CI: NR

ICER – unadjusted analysis: £117,681 per QALY gained.

95% CI: NR

: Abbreviations: ICER: incremental cost-effectiveness ratio; ICU: intensive care unit; n/a: not applicable; pADE: preventable adverse events; QALY: quality-adjusted life years; RCT: randomised controlled trial; SD: standard deviation.

(a): Some uncertainty regarding the applicability of resource use (2007-2008) and costs (2011) from Sweden to the current NHS context. It is not clear which EQ-5D tariff was used for calculating utilities. The intervention is delivered by junior pharmacists, which may not be the same to clinical pharmacist services delivered at UK hospitals.

(b): Relative effectiveness evidence is based on a single RCT, so by definition does not reflect all evidence in the area. Short follow-up, 6 months, so may not capture all relevant costs and outcomes.

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.

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

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

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

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)

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.

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

Chapter 30Pharmacist support

30. Pharmacist support

30.1. Introduction

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

30.3. Clinical evidence

Outcomes reported that were not analysable

30.4. Economic evidence

Published literature

30.5. Evidence statements

Clinical

Stratum - Regular in-hospital ward based pharmacy support

Stratum - Pharmacist at admission

Stratum - Pharmacist at discharge

Economic

Stratum - Regular ward-based pharmacist support

Stratum – pharmacist at admission

Stratum – pharmacist at discharge

30.6. Recommendations and link to evidence

References

Appendices

Appendix A. Review protocols

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

Appendix E. Economic evidence tables

E.1. Regular ward-based pharmacist support

E.2. Pharmacist at admission

E.3. Pharmacist at discharge

Appendix F. GRADE tables

Appendix G. Excluded clinical studies

Appendix H. Excluded economic studies

Footnotes

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Table 1PICO characteristics of review question

Table 2Summary of studies included in the review (regular in-hospital pharmacy support)

Table 3Summary of studies included in the review (pharmacist at admission)

Table 4Summary of studies included in the review (pharmacist at discharge)

Table 5Clinical evidence summary: Regular in-hospital ward based pharmacy support compared to no ward-based pharmacist

Table 6Clinical evidence summary: Pharmacist at admission compared to no ward-based pharmacist

Table 7Clinical evidence summary: Pharmacist at discharge compared to no ward-based pharmacist

Table 8Economic evidence profile: regular ward-based pharmacist support versus no ward-based pharmacist

Table 9Economic evidence profile: Pharmacist support at admission versus no ward-based pharmacist

Table 10Economic evidence profile: Pharmacist support at discharge versus no ward-based pharmacist

Table 11Review protocol: Pharmacist support

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

Figure 2Mortality

Figure 3Survival