Improving the Adherence of T2DM Patients With Pharmacy Care
Improving the Adherence of T2DM Patients With Pharmacy Care
The performed systematic review searched and analyzed randomized controlled trials on pharmacist interventions for patients taking oral type 2 diabetes medication with respect to adherence. In all six included studies the effect direction was in favor of the pharmacist interventions on improving adherence to antidiabetic medication. Overall, of the six included studies two studies showed a statistically significant effect of a Diabetes Care Plan combined with weekly in-person and/or telephone meetings and monthly follow-up telephone calls provided by pharmacists and of a pharmaceutical care intervention consisting of the provision of scheduled meetings with a pharmacist alongside with the physician's appointment compared with usual care.
However, the included studies contain in parts heterogeneous interventions as well as different methods to define, to operationalize and to measure adherence only allowing for a comparison to a limited extent. In five studies educational interventions (e.g. by telephone or as group activities) addressing topics such as disease, medication, diet, and lifestyle modification were evaluated. In three of these studies educational interventions were provided in addition to social services and nutrition consultation as well as reminders about annual eye and foot examinations, individual follow-up attendances, scheduled meetings with a pharmacist and/or usual care. Most interventions were compared with usual care whereas Adepu et al. and Grant et al. used a cut-down provision of educational interventions as the comparator. In addition, as mentioned, self-reported adherence as well as the prescription refill rate, the periodicity of prescription pickups and pill count were mainly implemented as the adherence measure in the included studies. Although these represent adherence measures commonly implemented, they might be subjected to overestimation of adherence.
Furthermore, besides changes in adherence rates all included studies measured in addition relevant clinical outcomes such as blood glucose and blood pressure values as their reduction and maintenance are key aims in diabetes care to prevent possible complications and to achieve health gains in diabetic patients. Statistically significant changes in blood pressure and blood glucose levels were found in favor of the intervention groups receiving pharmaceutical care in the majority of the studies. Other relevant outcomes such as knowledge and self-management as factors affecting adherence were also assessed. The involvement of a pharmacist contributed to an improvement of knowledge and self-care activities in three studies. However, different instruments were used for the assessment and knowledge as well as self-management values at the baseline and final assessment varied within and between the study groups among the studies. Moreover, the sample size was not adequately calculated in almost all of the studies or the sample size calculation was not reported.
A possible limitation is that pharmacists might individually differ in the way they provide their adherence-enhancing intervention. Additionally, they might show differences in identifying individual medication-related issues and patient needs, the intensity of the pharmacist-patient contact as well as in education and communication skills causing variances in outcomes. This issue has also been noted in other related publications. Moreover, an aspect to be considered is the fact that pharmacists in their respective health care systems, in which the studies were conducted, are differently integrated in the health care provision. For instance, in some health care systems pharmacist care might be more established and integrated as an organized element in the management of diseases as in other health care systems. Aspects such as education, professionalization, recognition and reimbursement just to mention some are essential influencing factors related to the differences in pharmacy care. The differences in the role of pharmacists in different countries contribute to the difficulty in comparing the different pharmacist interventions. Hence, making a generalized conclusion remains difficult, especially against the background that the analyzed randomized controlled trials are conducted in various different countries with varying living circumstances and cultural backgrounds.
We could not judge in how far the results of our quality assessment are in line with the quality assessment by Omran et al. as their results are not depicted in detail. In addition to the randomized controlled trials also identified by Omran et al. our review identified three further relevant randomized controlled trials. Two studies by Al Mazroui et al. and Skaer et al. which were included in the review by Omran et al. were not included in our review as they either did not fulfill our inclusion criteria or were not accessible.
The influence of pharmacist interventions in increasing adherence has been demonstrated in several publications, showing that the results of our review are in line with those of other publications, however, in how far health outcomes, quality of life or cost-effectiveness are improved is ambiguous. Thus, further studies of high quality are needed to assess significant effectiveness of adherence-enhancing pharmacist interventions care, especially against the background that the study quality of the included trials in this review are deficient.
Discussion
The performed systematic review searched and analyzed randomized controlled trials on pharmacist interventions for patients taking oral type 2 diabetes medication with respect to adherence. In all six included studies the effect direction was in favor of the pharmacist interventions on improving adherence to antidiabetic medication. Overall, of the six included studies two studies showed a statistically significant effect of a Diabetes Care Plan combined with weekly in-person and/or telephone meetings and monthly follow-up telephone calls provided by pharmacists and of a pharmaceutical care intervention consisting of the provision of scheduled meetings with a pharmacist alongside with the physician's appointment compared with usual care.
However, the included studies contain in parts heterogeneous interventions as well as different methods to define, to operationalize and to measure adherence only allowing for a comparison to a limited extent. In five studies educational interventions (e.g. by telephone or as group activities) addressing topics such as disease, medication, diet, and lifestyle modification were evaluated. In three of these studies educational interventions were provided in addition to social services and nutrition consultation as well as reminders about annual eye and foot examinations, individual follow-up attendances, scheduled meetings with a pharmacist and/or usual care. Most interventions were compared with usual care whereas Adepu et al. and Grant et al. used a cut-down provision of educational interventions as the comparator. In addition, as mentioned, self-reported adherence as well as the prescription refill rate, the periodicity of prescription pickups and pill count were mainly implemented as the adherence measure in the included studies. Although these represent adherence measures commonly implemented, they might be subjected to overestimation of adherence.
Furthermore, besides changes in adherence rates all included studies measured in addition relevant clinical outcomes such as blood glucose and blood pressure values as their reduction and maintenance are key aims in diabetes care to prevent possible complications and to achieve health gains in diabetic patients. Statistically significant changes in blood pressure and blood glucose levels were found in favor of the intervention groups receiving pharmaceutical care in the majority of the studies. Other relevant outcomes such as knowledge and self-management as factors affecting adherence were also assessed. The involvement of a pharmacist contributed to an improvement of knowledge and self-care activities in three studies. However, different instruments were used for the assessment and knowledge as well as self-management values at the baseline and final assessment varied within and between the study groups among the studies. Moreover, the sample size was not adequately calculated in almost all of the studies or the sample size calculation was not reported.
A possible limitation is that pharmacists might individually differ in the way they provide their adherence-enhancing intervention. Additionally, they might show differences in identifying individual medication-related issues and patient needs, the intensity of the pharmacist-patient contact as well as in education and communication skills causing variances in outcomes. This issue has also been noted in other related publications. Moreover, an aspect to be considered is the fact that pharmacists in their respective health care systems, in which the studies were conducted, are differently integrated in the health care provision. For instance, in some health care systems pharmacist care might be more established and integrated as an organized element in the management of diseases as in other health care systems. Aspects such as education, professionalization, recognition and reimbursement just to mention some are essential influencing factors related to the differences in pharmacy care. The differences in the role of pharmacists in different countries contribute to the difficulty in comparing the different pharmacist interventions. Hence, making a generalized conclusion remains difficult, especially against the background that the analyzed randomized controlled trials are conducted in various different countries with varying living circumstances and cultural backgrounds.
We could not judge in how far the results of our quality assessment are in line with the quality assessment by Omran et al. as their results are not depicted in detail. In addition to the randomized controlled trials also identified by Omran et al. our review identified three further relevant randomized controlled trials. Two studies by Al Mazroui et al. and Skaer et al. which were included in the review by Omran et al. were not included in our review as they either did not fulfill our inclusion criteria or were not accessible.
The influence of pharmacist interventions in increasing adherence has been demonstrated in several publications, showing that the results of our review are in line with those of other publications, however, in how far health outcomes, quality of life or cost-effectiveness are improved is ambiguous. Thus, further studies of high quality are needed to assess significant effectiveness of adherence-enhancing pharmacist interventions care, especially against the background that the study quality of the included trials in this review are deficient.