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Effect of Pharmacist’s Interventions on Glycemic Control in Diabetic Patients: A Systematic Review and Meta-analysis of Randomized Controlled TrialsNalinee Poolsup,1 Naeti Suksomboon,2* Methinee Intarates2 1 Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon-Pathom, 73000, Thailand 2 Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, 10400, Thailand
Abstract Several clinical trials have evaluated the effect of pharmacists’ interventions. However, the results have been inconsistent. We performed a systematic review to evaluate the effect of pharmacists’ interventions on glycemic control in diabetes. Clinical trials of pharmacists’ interventions aimed at improving glycemic control in diabetes patients were identified through a systematic search of MEDLINE, CINAHL, Web of Science, the Cochrane Library, and THAILIS. The bibliographic databases were searched from their inceptions to the end of February 2012. The references lists of relevant articles were checked and experts were consulted. Studies were included if they were: i) randomized controlled trials of pharmacists’ interventions aimed at improving glycemic control in diabetes patients, ii) reporting HbA1c
as an outcome measure, iii) published in English or Thai, and iv) clearly describing details of pharmacists’ intervention. Treatment effect was estimated with the mean difference in the change of HbA1c levels from baseline between the intervention and the control groups. Twenty-two trials involving 2,808 patients were included. Pharmacists’ interventions included an assessment and adjustment of anti-diabetic medications, identification of drug-related problems, co-operation with physicians and other members of the health care team, offering diabetes booklets and special medication containers, providing education concerning self-management of diabetes, and reinforcement of diabetes management with pharmacotherapy and non-pharmacotherapy. This meta-analysis showed that pharmacists’ interventions can improve glycemic control in diabetes patients (mean difference -0.68%, 95% CI -0.87% to -0.49%, p < 0.00001). Thus, pharmacists can play an important role in diabetes management.
Keyword: systematic review, pharmaceutical care, glycemic control, diabetes
INTRODUCTION Uncontrolled diabetes leads to micro-vascular complications, namely, retinopathy, nephropathy, and neuropathy, and macrovascular complications, namely, congestive heart failure (CHF), cerebrovascular disease (CVD), and peripheral arterial disease (PAD).1 Pharmacist has recently been involved in multidisciplinary team. The role of pharmacist in diabetes care, including discharged counseling and providing patient education regarding disease
and medication, especially, drug related problem (DRP) monitoring,2-4 is the most important responsibility of pharmacist to their patients for positive outcomes such as improving quality of life and keeping targeted goal of hemoglobin A1c (HbA1c). Evidence is clear that improving glycemic control and preventing complications result in significant cost saving and improved quality of life.5 There have been a large number of clinical trials evaluating pharmacists’
*Corresponding author: Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand. E-mail: naeti.suk@mahidol.ac.th
Original Article Mahidol University Journal of Pharmaceutical Sciences 2013; 40 (4), 17-30
N. Poolsup et al.18
interventions in diabetes mellitus (DM). However, the outcomes of these studies remain controversial. We conducted a systematic review and meta-analysis to assess the effect of pharmacists’ interventions on HbA1c level in diabetes patients.
METHODS Data sources
Reports of randomized controlled trials of pharmacists’ interventions aimed for good glycemic control in diabetes patients were identified through a systematic literature search of MEDLINE, CINAHL, the Cochrane Library, Web of Science, and the THAIland Library Integrated System (THAILIS). Literature searches were conducted from inception to the end of February 2012. The MeSH terms “pharmaceutical services”, “pharmacists”, and “diabetes mellitus” were used together with keywords “pharmaceutical care” and “pharmacy counseling”. Hand search was also performed on relevant journals in Thailand such as Journal of the Medical Association of Thailand, Thai Journal of Hospital Pharmacy. References of retrieved studies and reviews of the topic were hand searched and experts in the field were contacted for additional papers not captured by the search strategy.
Study selection
The studies were included in the review if they: 1) were randomized controlled trials of any pharmacists’ interventions compared with usual care in diabetes patients, including type 1, type 2, Gestational diabetes mellitus (GDM), or unspecified DM; 2) reported HbA1c as an outcome measure; 3) were published in English or Thai language; and 4) clearly described pharmacists’ intervention. Abstract presenta-tion was excluded.
Data extraction and quality assessment
Data extraction and study quality assessment were performed independently by two investigators using a standardized form. Disagreements were resolved by a third investigator. Data from individual studies were abstracted. Data recorded were
the year of publication, setting, country, duration of study, intervention frequency, number of visit, inclusion criteria and exclusion criteria of each trial, type of DM, concomitant drug and disease, sample size, age, duration of DM, details of pharmacists’ interventions and control intervention, and primary outcomes. Quality of randomized controlled trials included in this review was assessed using Maastricht-Amsterdam scale.6 The scale comprises 11 items to evaluate internal validity of the study results. Studies that met at least 6 of 11 quality criteria were of high quality. Those scoring less than 6 of the criteria were of low quality.
Statistical analysis
Treatment effect was estimated with a mean difference in the change of HbA1c level from baseline to final assessment between the intervention group and the control group. If the variances of change values were not provided, but the exact p-value of the mean difference between the intervention and the control groups was available, the p-value was used to impute the variance.7 If the variances of change values and the exact p-values of the mean difference were not provided, the pooled interstudy variances were imputed from studies reporting variances. The inverse variance-weighted method was used for the pooling of mean difference and the estimation of 95% confidence interval (CI).8 A random effects model was used when the Q-statistic for heterogeneity was significant at the level of 0.1,9 otherwise the fixed effects model was used.8 The degree of heterogeneity was quantified using the I2 statistic which is the percentage of total variation across studies due to heterogeneity.10 A funnel plot and Egger’s method11 were performed to assess publication bias. Statistical analysis was undertaken with RevMan version 5.1 (Cochrane Collaboration, Oxford, UK). The significant level was set at p < 0.05.
RESULTS Study characteristics
The initial search of the computerized
19Effect of Pharmacist’s Interventions on Glycemic Control in Diabetic Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials
database and hand search identified a total of 1,160 articles (Figure 1). After the initial screening, 44 trials were attained in the selection process. Among the 44 trials, 16 trials were excluded because they did not report glycemic control/HbA1c. Five trials were further excluded because they did not state clearly the role of pharmacist in the intervention group. One trial reported results in terms of median and interquartile range
and was then excluded. Only 22 randomized controlled trials met inclusion criteria and were included in the systematic review and meta-analysis. Characteristics of these trials are presented in Table 1. In general, there were no significant differences between patients in the intervention group and those in the control group with respect to age and duration of diabetes.
Figure 1. Flow diagram of study selection for meta-analysis
Those trials, involved patients with type 1, type 2, GDM, or unspecified DM and were reported between 1996 and 2012. The setting of trials included primary care unit, home care, community pharmacy, primary care hospital, tertiary care hospital, a university-affiliated internal medicine outpatient clinic, endocrine clinic, military hospital, and veteran medical center in the USA, Canada, Australia, Sweden, Spain, UAE, and Thailand. The duration of trials varied from 3 months to 2 years. Pharmacists’ intervention was given at different frequency, for example, once a week and once every 6 months. Number of visit ranged between 1 and 24 times. Pharmacists involved included registered pharmacist,12,20,26,32 clinical pharmacist,14,16-18,21,23,25,27,29,30 community pharmacist,22,24,28,32 clinical pharmacist with multidisciplinary team,19,31 certified diabetes educator pharmacists,13 specially trained pharmacists.15 The methods of follow-up were
face-to-face encounter and/or by telephone. Details of pharmacist’ interventions differed from trial to trial (Table 2 and 3) and encompassed the followings: diabetes education and counseling about drug, disease, diet, exercise, life style modification, and self-management, assessment and adjustment of antidiabetic medications, identifying and solving drug-related problems, co-operating with physician and other diabetes health care team, providing materials, leaflet, diabetes booklet and special medication containers, and monthly newsletter that enforced patients to achieve a target goal, reminding about annual eye and foot examinations, and providing additional information about smoking cessation, stop drinking alcohol. For the usual care group, patients continued to receive standard medical care provided by their physicians, other health care team, and with/without pharmacists depending on each study design (Table 2).
N. Poolsup et al.20
No.
St
udy
Setti
ng
Cou
ntry
D
urat
ion
In
terv
entio
n In
clus
ion
of
stud
y fr
eque
ncy
crite
ria
1
Jabe
r LA
199
612
A U
nive
rsity
-affi
liate
d in
tern
al
US
4 m
o 2-
4 w
eeks
/tim
e T2
DM
m
edic
ine
outp
atie
nt cl
inic
2 G
uirg
uis L
M 2
00113
C
hain
pha
rmac
y, sh
oppe
rs
Can
ada;
6
mo
< 1
mon
th/ti
me
T2D
M fo
r Alb
erta
a m
inim
um
drug
mar
t Ed
mon
ton,
of
1 y
ear,
non-
inst
itutio
naliz
ed
3 C
liffor
d RM
200
214
Frem
entle
Hos
pita
l,
Aust
ralia
6
mo
6 w
eeks
/tim
e A
ged
> 18
yea
rs w
ith e
ither
T1D
M
diab
etes
out
patie
nt cl
inic
or T
2DM
and
was
hig
h-ris
k
for t
he d
evel
opm
ent o
f dia
bete
s
com
plic
atio
ns.
4
Sark
adi A
200
415
Stoc
khol
m D
iabe
tes A
ssoc
iatio
n Sw
eden
24
mo
6 m
onth
s/tim
e T2
DM
and
, if t
reat
ed w
ith in
sulin
,
only
for 2
yea
rs o
r les
s
5 C
liffor
d RM
200
516
Frem
entle
Hos
pita
l, Fr
emen
tle
Aust
ralia
12
mo
6 w
eeks
/tim
e T2
DM
D
iabe
tes S
tudy
(FD
S)
6
Cho
e H
M 2
00517
U
nive
rsity
-affi
liate
d pr
imar
y
US
24 m
o 1
mon
th/ti
me
T2D
M, H
bA1c
leve
ls >
8.0%
ca
re in
tern
al m
edic
ine
clin
ic
7
Ode
gard
PS
2005
18
The
Uni
vers
ity o
f Was
hing
ton
US
6 m
o 1
wee
k/tim
e A
ged
≥ 18
yea
rs, T
2DM
, tak
ing
at
med
icin
e cl
inic
s
leas
t one
ora
l dia
bete
s med
icat
ion,
w
ith a
n H
bA1c
≥9%
8
Suks
ombo
on N
2005
19
Prim
ary
care
uni
t, Sa
mut
sako
rn
Thai
land
3
mo
3 m
onth
s/tim
e T2
DM
, 18-
60 y
ears
old
, tak
e O
AD
H
ospi
tal
as
met
form
in, g
lipiz
ide
and/
or
glib
encl
amid
e, H
bA1c
> 7
%
9 Su
ppap
itipo
rn S
200
520
Endo
crin
e cl
inic
in K
ing
Th
aila
nd
6 m
o 3
mon
ths/
time
T2D
M, a
ged
> 40
yea
rs
Chu
lalo
ngko
rn M
emor
ial
H
ospi
tal (
out p
atie
nts)
10
Ro
thm
an R
L 20
0521
U
nive
rsity
of N
orth
Car
olin
a
US
12 m
o 2-
4 w
eeks
/tim
e A
ged
>18
year
s old
, T2D
M, H
bA1c
G
ener
al In
tern
al M
edic
ine
leve
l >8.
0%, l
ife e
xpec
tanc
y >6
Pr
actic
e
mon
ths
11
Forn
os JA
200
622
Com
mun
ity p
harm
acie
s Sp
ain;
13
mo
1 m
onth
/tim
e tr
eatm
ent w
ith o
ral a
ntid
iabe
tics
Pont
eved
ra
for m
ore
than
2 m
onth
s
12
Scot
t DM
200
623
Siou
xlan
d C
omm
unity
Hea
lth
US
9 m
o 2
wee
ks/ti
me
T2D
M, a
ged
> 18
yea
rs
Cen
ter (
SCH
C)
Tabl
e 1. C
hara
cter
istic
s of t
he st
udie
s inc
lude
d in
the m
eta-
anal
ysis
21Effect of Pharmacist’s Interventions on Glycemic Control in Diabetic Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials
No.
St
udy
Setti
ng
Cou
ntry
D
urat
ion
In
terv
entio
n In
clus
ion
of
stud
y fr
eque
ncy
crite
ria
13
K
rass
I 20
0724
C
omm
uniti
es p
harm
acie
s
Aust
ralia
6
mo
1 m
onth
/tim
e T2
DM
, HbA
1c ≥
7.5
%, t
akin
g at
leas
t
one o
ral g
luco
se lo
werin
g m
edica
tion
or
insu
lin, o
r HbA
1c ≥
7.0
%, t
akin
g at
leas
t
one o
ral g
luco
se lo
wer
ing
med
icat
ion
or
insu
lin, o
n at
leas
t one
anti-
hype
r-
tens
ive,
angi
na o
r lip
id-lo
wer
ing
drug
.
14
Elno
ur A
A 2
00825
A
l Ain
Hos
pita
l, gy
naec
olog
y
UA
E 6
mo
1 m
onth
/tim
e Pa
tient
pro
vide
d wi
thin
the fi
rst 20
wee
ks
outp
atie
nt cl
inic
s
of g
esta
tion,
dia
gnos
is o
f GD
M, a
nd
ag
ed 2
0- 3
9 ye
ars
15
Ph
umip
amor
n S
2008
26
Com
mun
ity h
ospi
tal i
n K
rabi
Th
aila
nd
10 m
o 2
mon
ths/
time
Mus
lim d
iabe
tic p
atie
nts,
aged
> 1
8
prov
ince
year
s, an
d H
bA1c
> 7
%
16
Pa
vasu
dthi
paisi
t A 2
00927
Dia
bete
s Clin
ic, O
ut-p
atie
nt
Thai
land
12
mo
6 m
onth
s/tim
e T2
DM
, HbA
1c le
vels
> 8.
0% w
ithou
t
depa
rtm
ent,
Non
gbua
lam
phu
m
acro
vasc
ular
com
plic
atio
ns
hosp
ital
17
D
ouce
tte W
R 20
0928
C
omm
unity
pha
rmac
y pr
actic
e site
US;
IOW
A
12 m
o 3
mon
ths/
time
T2D
M, H
bA1c
> 7
.0%
18
M
azro
ui N
RA 2
00929
Za
yed
Mili
tary
Hos
pita
l, ge
nera
l U
AE
12 m
o 4
mon
ths/
time
T2D
M, r
ecei
ving
ora
l hyp
ogly
caem
ic
med
ical
war
ds a
nd e
ndoc
rinol
ogy
th
erap
y
& m
edic
al o
utpa
tient
clin
ics
19
Tave
ira T
H 2
01030
Ve
tera
ns H
ealth
Affa
irs
US
22 m
o 4
wee
ks/ti
me
T2D
M, a
ged
> 18
year
s, or
HbA
1c 7%
-9%
w
ithin
the
prev
ious
6 m
onth
s
20
Ed
elm
an D
201
031
Vete
rans
Affa
irs M
edic
al C
ente
rs U
S; C
arol
ina
12.8
mo
2 m
onth
s/tim
e Pa
tient
s had
bot
h di
abet
es an
d hy
per-
& V
irgin
ia
tens
ion,
rec
eivi
ng m
edic
atio
n fo
r
diab
etes
, and
HbA
1c le
vel >
7.5%
and
hype
rten
sion
(SBP
>14
0 m
m H
g or
DBP
>90
mm
Hg)
21
M
ehuy
s E 2
01132
C
omm
unity
pha
rmac
ies
Belg
ium
6
mo
6 w
eeks
/tim
e T2
DM
, rec
eivi
ng o
ral h
ypog
lyca
emic
med
icat
ion
for a
t lea
st 12
mon
ths,
aged
45 –
75
year
s, BM
I> 2
5 kg
/m2,
and
regu
lar v
isito
r of p
harm
acy
22
Srira
m S
201
133
A p
rivat
e te
rtia
ry c
are
hosp
ital
Sou
th In
dia
8 m
o 3
mon
ths/
time
Indi
an, T
2DM
, age
d >
18 y
ears
, with
or
with
out o
ther
dise
ases
Tabl
e 1. C
hara
cter
istic
s of t
he st
udie
s inc
lude
d in
the m
eta-
anal
ysis
(con
t.)
N. Poolsup et al.22
No.
St
udy
Phar
mac
ist in
terv
entio
n U
sual
car
e
1 J
aber
LA
199
612
Dia
bete
s edu
catio
n, m
edic
atio
n co
unse
ling,
inst
ruct
ions
on
diet
ary
Con
tinue
d to
rece
ive
stan
dard
med
ical
car
e pr
ovid
ed b
y
regu
latio
n, e
xerc
ise, a
nd h
ome
bloo
d gl
ucos
e m
onito
ring,
and
th
eir p
hysic
ians
.
eval
uatio
n an
d ad
just
men
t of t
heir
hypo
glyc
emic
regi
men
.
2 G
uirg
uis L
M 20
0113
Usu
al c
are
plus
serv
ice
prov
ide;
dia
bete
s and
its c
ompl
icat
ion,
C
ontr
ol p
harm
acie
s pro
vide
d us
ual c
are,
phar
mac
ist
hypo
glyc
emia
, mon
itorin
g bl
ood
gluc
ose
leve
l, us
e of
off
ered
pat
ient
s som
e fo
rm o
f blo
od g
luco
se
bloo
d gl
ucos
e m
onito
r, nu
triti
on, e
xerc
ise, i
nsul
in u
se, i
nsul
in
met
er tr
aini
ng ,
othe
r tra
inin
g on
dia
bete
s man
agem
ent
de
vice
, med
icat
ion
use,
and
foot
car
e; a
nd te
achi
ng p
rovi
de;
(in-s
tore
cour
ses o
r con
tinui
ng e
duca
tion
cour
se).
ev
alua
ted
teac
hing
nee
ds, a
ddre
ssed
par
ticip
ant c
once
rns,
revi
ewed
blo
od g
luco
se le
vels,
revi
ewed
HbA
1c, m
easu
red
BP,
re
view
ed ch
oles
tero
l lev
els,
scre
ened
for m
icro
albu
min
uria
, rev
iew
ed
m
edic
atio
n pr
ofile
, adv
ised
on n
on-p
resc
riptio
n m
edic
atio
ns,
co
ntac
ted
phys
icia
n, co
ntac
ted
othe
r mem
bers
of d
iabe
tes t
eam
, and
met
er m
aint
enan
ce.
3 C
liffor
d RM
200
214 C
ompl
eted
a co
mpr
ehen
sive,
self-
dire
cted
revi
sion
of d
iabe
tes
Rece
ived
stan
dard
out
patie
nt c
are,
not c
ompl
eted
m
anag
emen
t prio
r to
the
stud
y, sa
w e
ach
patie
nt at
eve
ry v
isit,
and
the
patie
nt sa
tisfa
ctio
n su
rvey
.
co-o
pera
tion
with
the
diab
etes
phy
sicia
n an
d ot
her h
ealth
team
. 4
Sar
kadi
A 2
00415
Th
e ed
ucat
iona
l pro
gram
; a v
ideo
on
how
to “l
ive
wel
l” w
ith d
iabe
tes,
Usu
al c
are
and
assig
ned
to a
wai
ting
list o
f 2 y
ears
, the
n
exem
plify
ing
lifes
tyle
chan
ges m
ade
by th
ose
inte
rvie
wed
, a d
ice
gam
e th
ey w
ere i
nvite
d to
par
ticip
ate i
n th
e edu
catio
nal p
rogr
am.
w
here
que
stio
ns h
ad to
be
answ
ered
, and
a b
ookl
et o
r gui
de o
n
“how
to m
anag
e yo
ur d
iabe
tes”.
5 C
liffor
d RM
200
516 F
ace-
to-fa
ce m
eetin
g go
al-d
irect
ed m
edic
atio
n an
d lif
esty
le co
unse
ling,
H
ad a
stan
dard
ass
essm
ent b
y pr
imar
y ca
re p
hysic
ian.
te
leph
one
asse
ssm
ents
and
pro
visio
n of
oth
er e
duca
tiona
l mat
eria
l 6
Cho
e HM
200
517
Phar
mac
ists p
rovi
ded
eval
uatio
n an
d m
odifi
catio
n of
pha
rmac
othe
rapy
, Kep
t as a
nat
ural
cont
rol,
they
rece
ived
onl
y re
gula
r car
e
self-
man
agem
ent d
iabe
tes e
duca
tion,
and
rein
forc
emen
t of d
iabe
tes
incl
udin
g re
gula
r fol
low
up
visit
s with
thei
r prim
ary
care
co
mpl
icatio
ns sc
reen
ing p
roce
sses
thro
ugh
clini
c visi
ts an
d tel
epho
ne fo
llow-
up. p
hysic
ians
, rec
eive
d no
spec
ial c
onta
ct d
urin
g th
e
inte
rven
tion,
did
not
hav
e ex
it in
terv
iew
s or p
roce
ss
mea
sure
men
ts at
the
end
of th
e st
udy.
Tabl
e 2. D
etai
ls of
pha
rmac
ists’
inte
rven
tion
and
usua
l car
e of e
ach
tria
l
23Effect of Pharmacist’s Interventions on Glycemic Control in Diabetic Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials
No.
St
udy
Phar
mac
ist in
terv
entio
n U
sual
car
e
7 O
dega
rd P
S 200
518
The
phar
mac
ist in
terv
entio
n w
as co
mpo
sed
of d
evel
opm
ent o
f a
Patie
nts w
ere
cons
truc
ted
to co
ntin
ue n
orm
al c
are
di
abet
es ca
re p
lan
(DC
P), r
egul
ar p
harm
acist
-pat
ient
com
mun
icat
ion
on w
ith th
eir p
rimar
y ca
re p
rovi
der.
Dia
bete
s edu
catio
n
diab
etes
care
pro
gres
s, ph
arm
acist
-pro
vide
r com
mun
icat
ion
on th
e sub
ject
’s wa
s not
pro
vide
d du
ring
the b
aseli
ne in
terv
iew
to av
oid
di
abet
es c
are
prog
ress
, and
DRP
. in
trodu
cing a
n in
terv
entio
n fo
r pat
ients
in th
e con
trol g
roup
. 8
Suk
som
boon
Se
lf-effi
cacy
trai
ning
pro
gram
by
mul
tidisc
iplin
ary
team
incl
udin
g
The
cont
rol g
roup
did
not
ent
er p
erce
ived
self-
effica
cy
N
200
519
phar
mac
ist, p
harm
acist
also
pro
vide
d ed
ucat
ion
on se
lf-ca
re b
ehav
iors
, tr
aini
ng p
rogr
am.
se
lf-m
onito
ring
of b
lood
glu
cose
, and
kno
wle
dge
in d
iabe
tes.
9 S
uppa
pitip
orn
U
sual
car
e pl
us d
iabe
tic d
rug
coun
selin
g, a
dded
dia
bete
s boo
klet
, spe
cial
Pat
ient
s wer
e in
terv
iew
ed d
emog
raph
ic in
form
atio
n,
S
2005
20
med
icat
ion
cont
aine
rs.
bloo
d te
st, a
nd m
edic
al re
cord
s. 1
0 Ro
thm
an
Inte
nsiv
e ed
ucat
ion
sess
ions
, evi
denc
e-ba
sed
algo
rithm
, pro
activ
e Pa
tient
s rec
eive
d us
ual c
are
from
thei
r prim
ary
care
RL 2
00521
m
anag
emen
t. pr
ovid
er a
nd h
ad n
o fu
rthe
r man
agem
ent f
rom
the
dise
ase
man
agem
ent t
eam
. 1
1 Fo
rnos
U
sual
car
e pl
us p
harm
acot
hera
py fo
llow
up
prog
ram
(ind
ivid
ualiz
ed
Usu
al d
ispen
sing
by p
harm
acist
.
JA
200
6 22
pr
ogra
m) w
hich
cons
ists o
f the
det
ectio
n an
d re
solu
tion
of D
RPs
an
d di
abet
es e
duca
tion,
invo
lves
pat
ient
s in
thei
r ow
n ca
re in
ord
er to
obta
in m
axim
um b
enefi
t fro
m th
e m
edic
atio
n. 1
2 Sc
ott
Patie
nt ed
ucat
ion
abou
t dise
ase,
testi
ng b
lood
glu
cose
leve
ls, d
rug
ther
apy,
Patie
nts r
ecei
ved
stan
dard
dia
bete
s car
e an
d w
ere
DM
200
623
psyc
holo
gica
l adj
ustm
ent i
n di
abet
es, s
igns
and
sym
ptom
s of h
yper
- m
anag
ed b
y a
nurs
e.
glyc
emia
, hyp
ergl
ycem
ia, a
nd d
iabe
tic k
etoa
cido
sis an
d co
urse
of a
ctio
n. 1
3 K
rass
I 20
0724
Se
rvic
es fr
om p
harm
acist
s inc
lude
d of
revi
ew o
f sel
f mon
itorin
g of
Th
e con
trol p
atien
ts ha
d tw
o vi
sits w
ith th
e pha
rmac
ist,
bl
ood
gluc
ose;
dise
ase,
med
icat
ion,
and
life
styl
e ed
ucat
ion;
adh
eren
ce
one
at th
e be
ginn
ing
and
one
at th
e en
d of
the
stud
y.
supp
ort a
nd d
etec
tion
of d
rug-
rela
ted
prob
lem
s; an
d re
ferr
als t
o th
e
Dur
ing t
he in
terv
enin
g 6 m
onth
s, th
ey re
ceiv
ed ‘u
sual
care
’
patie
nts’
GPs
whe
n ap
prop
riate
. (
i.e. n
o sp
ecia
lized
dia
bete
s ser
vice
in th
e ph
arm
acy)
. 1
4 El
nour
En
sure
d th
at in
terv
entio
n pa
tient
s rec
eive
d ba
sed
trea
tmen
t and
Pa
tient
s rec
eive
d tr
aditi
onal
car
e: m
onth
ly cl
inic
visi
ts
A
A 2
00825
tr
eatm
ent f
or a
ny o
ther
conc
omita
nt il
lnes
s, ed
ucat
ed o
n G
DM
an
d se
lf-m
onito
ring
of p
lasm
a gl
ucos
e us
ing
diar
y ca
rds.
an
d its
man
agem
ent,
educ
atio
nal b
ookl
et, C
linic
al a
sses
smen
ts.
Tabl
e 2. D
etai
ls of
pha
rmac
ists’
inte
rven
tion
and
usua
l car
e of e
ach
tria
l (co
nt.)
N. Poolsup et al.24
No.
St
udy
Phar
mac
ist in
terv
entio
n U
sual
car
e
15
Phu
mip
amor
n
Usu
al c
are
plus
rem
inde
d th
e pa
tient
s, re
fille
d pr
escr
iptio
ns,
Patie
nts r
ecei
ved
usua
l sch
edul
e ca
re b
y pr
imar
y ca
re
S
2008
26
disc
usse
d th
e use
s of m
edic
atio
n, ch
eck
the p
ill co
unt,
educ
atio
n on
ph
ysic
ian
ever
y 4-
8 w
eeks
., di
spen
sing
by p
harm
acist
di
abet
es ab
out a
ppro
pria
te li
festy
le, co
rrec
t die
t, an
d pr
ovid
ed d
iabe
tic
fille
d an
d ga
ve g
ener
al a
dvic
e on
med
icat
ion
uses
ove
r
pam
phle
t; di
abet
ic co
mpl
icat
ions
, tar
get o
f tre
atin
g di
abet
es, l
ife st
yle
the
disp
ensa
ry co
unte
r on
a ro
utin
e ba
sis.
ch
ange
, and
dia
betic
med
icat
ions
. 1
6 Pa
vasu
dthi
paisi
t In
terv
entio
n gr
oup
rece
ived
inte
nsiv
e man
agem
ent f
rom
pha
rmac
ist
Patie
nts w
ere p
rovi
ded
care
by
thei
r phy
sicia
ns o
f int
erns
.
A
200
927
prac
titio
ners
; rec
eive
d an
asse
ssm
ent o
f med
icat
ion-
taki
ng ad
here
nce
an
d th
eir u
nder
stan
ding
of d
iabe
tes t
hen
appl
ied
algo
rithm
s for
m
anag
ing
gluc
ose
cont
rol a
nd o
ther
car
diov
ascu
lar r
isk fa
ctor
s. 1
7 D
ouce
tte
Disc
ussin
g m
edic
atio
ns, c
linic
al g
oals,
self-
care
activ
ities
with
pat
ient
s Pa
tient
s rec
eive
d us
ual d
iabe
tes c
are
from
thei
r prim
ary
WR
2009
28
and
reco
mm
endi
ng m
edic
atio
n ch
ange
s to
phys
icia
ns w
hen
appr
opria
te.
care
pro
vide
r. 1
8 M
azro
ui
The r
esea
rch
phar
mac
ist h
ad d
iscus
sions
with
thei
r phy
sicia
ns re
gard
ing
Patie
nts r
ecei
ved
norm
al c
are
from
med
ical
and
nur
sing
NRA
200
929
drug
ther
apy,
trea
tmen
t mod
ifica
tion,
edu
cate
d fo
r illn
ess a
nd
staff
, did
not
rece
ive
the
clin
ical
pha
rmac
y se
rvic
e.
med
icat
ion,
prin
ted
leafl
et, a
nd b
ehav
iora
l mod
ifica
tion.
19
Tave
ira
Usu
al c
are
plus
trea
tmen
t of h
yper
glyc
emia
, hyp
erte
nsio
n,
Patie
nts r
ecei
ved
the
stan
dard
car
e pr
ovid
ed b
y pr
imar
y
TH
201
030
hype
rlipi
dem
ia, a
nd ci
gare
tte sm
okin
g.
care
pro
vide
rs, f
requ
ency
aver
age
4 m
onth
s. 2
0 Ed
elm
an
Phar
mac
ist re
view
ed p
atie
nt m
edic
al re
cord
s, BP
, and
hom
e bl
ood
Pa
tient
s con
tinue
d to
rece
ive
thei
r usu
al p
rimar
y ca
re,
D 2
01031
gl
ucos
e re
adin
gs d
urin
g ea
ch se
ssio
n an
d de
velo
ped
indi
vidu
aliz
ed
no a
ctiv
e in
terv
entio
n.
plan
s for
med
icat
ion
or li
festy
le m
anag
emen
t. Ph
arm
acist
and
phys
icia
n
adju
sted
med
icat
ion
to m
anag
e ea
ch p
atie
nt H
bA1c
leve
l and
BP.
21
Meh
uys
Educ
atio
n ab
out T
2DM
and
com
plic
atio
ns, c
orre
ct u
se o
f ora
l Pa
tient
s rec
eive
d us
ual p
harm
acist
car
e.
E
2011
32
hypo
glyc
aem
ic a
gent
s, fa
cilit
atio
n of
med
icat
ion
adhe
renc
e, he
alth
y
lifes
tyle
edu
catio
n, a
nd re
min
ders
abo
ut a
nnua
l eye
and
foot
ex
amin
atio
ns.
22
Srira
m S
201
133
Patie
nts r
ecei
ved
phar
mac
eutic
al ca
re; m
edic
atio
n co
unse
ling
instr
uctio
ns P
atie
nts r
ecei
ved
usua
l dia
bete
s car
e.
on d
ieta
ry re
gula
tion,
exe
rcise
and
oth
er li
fest
yle
mod
ifica
tion.
Tabl
e 2. D
etai
ls of
pha
rmac
ists’
inte
rven
tion
and
usua
l car
e of e
ach
tria
l (co
nt.)
25Effect of Pharmacist’s Interventions on Glycemic Control in Diabetic Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials
Effect on HbA1c
Twenty two trials involving a total of 2,808 diabetes patients were pooled. HbA1c levels at baseline, final assessment are presented in Table 4. HbA1c levels were significantly reduced with pharmacists’ interventions
compared with usual care. The pooled mean difference in the change of HbA1c was -0.68% (95%CI, -0.87% to -0.49%; p< 0.00001) (Figure 2). No publication bias was detected (Egger bias -0.35; 95% CI -2.89 to 2.19, P= 0.7785).
Table 3. Component of pharmacists’ intervention in individual trials
Education
Identifying and Study Materials provided
and counseling resolving drug-
related problems
Jaber LA 199612 - ✓ ✓ Guirguis LM 200113 glucose meter maintenance ✓ - Clifford RM 200214 - ✓ ✓ Sarkadi A 200415 video, booklet ✓ ✓ Clifford RM 200516 educational material ✓ ✓ Choe HM 200517 - ✓ ✓ Odegard PS 200518 - - ✓ Suksomboon N 200519 - ✓ - Suppapitiporn S 200520 booklet, containers ✓ - Rothman RL 200521 - ✓ - Fornos JA 200622 - ✓ ✓ Scott DM 200623 - ✓ ✓ Krass I 200724 monthly newsletter ✓ ✓ Elnour AA 200825 booklet ✓ ✓ Phumipamorn S 200826 pamphlet ✓ ✓ Pavasudthipaisit A 200927 - ✓ ✓ Doucette WR 200928 - ✓ ✓ Mazroui NRA 200929 leaflet ✓ - Taveira TH 201030 smoking cessation handout ✓ - Edelman D 201031 - ✓ ✓ Mehuys E 201132 educational material ✓ -
Sriram S 201133 leaflet, diabetic diet ✓ ✓ chart, diabetic diary
N. Poolsup et al.26
HbA1c (%)
Study Control Intervention
Baseline Final Baseline Final
Jaber LA 199612 11.5±2.9 12.1±3.3 12.2±3.5 9.2±2.1 Guirguis LM 200113 7.9* 7.1* 7.9* 6.9* Clifford RM 200214 8.5±1.6 8.1±1.6 8.4±1.4 8.2±1.5 Sarkadi A 200415 6.44* 6.60* 6.44* 6.09* Clifford RM 200516 7.1* 6.7* 7.5* 7.3* Choe HM 200517 10.2±1.7 9.3±2.1 10.1±1.8 8.0±1.4 Odegard PS 200518 10.6±1.4 9.2* 10.2±0.8 8.7* Suksomboon N 200519 9.73±1.88 10.23±2.59 9.03±1.67 8.69±1.82 Suppapitiporn S 200520 8.01±1.51 8.80±1.36 8.16±1.44 7.91±1.27 Rothman RL 200521 11±2 9.4* 11±3 8.5* Fornos JA 200622 7.8±1.7 8.5±1.9 8.4±1.8 7.9±1.7 Scott DM 200623 8.7* 8.0* 8.8* 7.08* Krass I 200724 8.3±1.3 8.0±1.2 8.9±1.4 7.9±1.2 Elnour AA 200825 6.87 6.55 6.85 6.38 (95%CI (95%CI (95%CI (95%CI 6.81, 6.93) 6.43, 6.67) 6.78, 6.90) 6.33, 6.42) Phumipamorn S 200826 8.7±1.6 8.1±1.9 8.7±1.5 7.9±1.4 Pavasudthipaisit A 201127 9.9±1.6 9.1* 9.8±1.4 7.8* Doucette WR 200928 7.91±1.91 8.03* 7.99±1.45 7.72* Mazroui NRA 200929 8.4 8.3 8.5 6.9 (95%CI (95%CI (95%CI (95%CI 8.6, 8.6) 8.1, 8.5) 8.3, 8.7) 6.7, 7.1) Taveira TH 201030 7.9±1.1 7.9* 8.1±1.5 7.2* Edelman D 201031 9.2±1.3 8.6* 9.2±1.5 8.3* Mehuys E 201132 7.3 ± 1.2 7.2 ± 1.0 7.7 ± 1.7 7.1 ± 1.1 Sriram S 201133 9.03 ± 0.46 8.31 ± 0.16 8.44 ± 0.29 6.73 ± 0.21
Data are mean±SD, * mean value
Table 4. HbA1c levels at baseline and final assessment reported in individual trials
27Effect of Pharmacist’s Interventions on Glycemic Control in Diabetic Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials
DISCUSSION
Pharmacist is part of a multidiscip-linary team. This team normally consists of pharmacist, physician, nurse, technician, nutritionist, and other health care professions. All of the members in multidisciplinary team have important roles in diabetes management in achieving the goal of treatment, improving quality of life, controlling disease and its complications, delaying complication, and decreasing mortality and morbidity. Pharma-cists’ interventions are an important factor to improve glycemic control in diabetic patients. Pharmacists’ interventions include diabetes education and counseling on drug, disease, diet, exercise, life style modification, and self-management, assessment and adjustment of anti-diabetic medications, identifying and solving drug-related problems, co-operation with physician and other diabetes health care team, providing materials that reinforce patients to achieve a target goal, providing additional information on smoking cessation. All of these interventions aimed at improving glycemic control. In our study, HbA1c levels significantly reduced with pharmacists’ interventions compared with usual care. The pooled mean
difference in the change of HbA1c was -0.68% (95%CI, -0.87% to -0.49%; p< 0.00001). This reduction is the same as the ability in reducing HbA1c by taking some oral anti-hyperglycemic drugs for example, DPP-4 inhibitors and alpha-glucosidase inhibitors. This would help patients meeting the target of their treatment. To ensure that the meta-analysis included quality study, the Maastricht Amsterdam scale was used to assess the quality of individual study. The majority of the studies12-13, 15-20, 22-31,33 were rated as low quality, only three studies14, 21, 32 were of high quality. Most of these studies were open (not blinded) in study design. Performance bias in both intervention and control groups was likely in these trials as patients may seek other interventions to help control their blood glucose. This was evident when only high quality studies14, 21, 32 were pooled, showing a slight reduction in the effect of pharmacists’ interventions on HbA1c (mean difference -0.39%, 95% CI -0.61% to -0.17%, p = 0.0005). There were limitations in individual studies included in this meta-analysis. In most of the trials, both pharmacists and patients were not blinded and therefore,
Figure 2. Mean difference (95% confidence interval) of HbA1c between pharmacist intervention group and usual care group
N. Poolsup et al.28
contamination between groups was possible. This may affect the final outcomes. Secondly, Hawthorne effect may occur when study participants improved because of the only fact that they were participating in a research study. The findings of our study suggest several practice implications. First, pharma-cists’ interventions effectively improve glycemic control when compared with usual care; and thus, pharmacist should be part of a diabetes care team. Second, the approprite components of intervention should include both pharmacotherapy and non-pharmaco-therapy. Interventions on pharmacotherapy are screening and solving drug-related problems; if necessary, pharmacists provide feedback to physician, deliver patient education and counseling on medication. Non-pharmacotherapy interventions include education and counseling on diet, exercise, disease, adherence, and life-style modification.
CONCLUSION
The available evidence suggests that pharmacists’ interventions are more effective than usual care in decreasing HbA1c levels in diabetes patients. Pharmacists’ interventions included diabetes education and counseling on drug, disease, diet, exercise, life style modification, and self-management, an assessment and adjustment of anti-diabetic medications, identifying and solving drug-related problems, co-operation with physician and other diabetes health care team.
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