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
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Appendices
Appendix A. Review protocols
Table 11
Review protocol: Pharmacist support.
Appendix B. Clinical article selection
Appendix C. Forest plots
C.1. Regular in-hospital pharmacist support
C.2. Pharmacist at admission
Appendix D. Clinical evidence tables
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Appendix E. Economic evidence tables
E.1. Regular ward-based pharmacist support
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E.2. Pharmacist at admission
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E.3. Pharmacist at discharge
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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
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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.