Sensitivity of patient outcomes to pharmacist interventions. Part I: systematic review and meta-analysis in diabetes management.
BACKGROUND
Pharmacists participate in managing diabetes therapy. Despite many reviews, few have quantified the impact of pharmacists' interventions.


OBJECTIVE
To identify outcomes sensitive to pharmacists' interventions and quantify their impact through critical literature review.


METHODS
All original research describing the impact of pharmacists' interventions in the management of diabetic pharmacotherapy was sought in International Pharmaceutical Abstracts, MEDLINE, Embase, Cochrane Register, and Cumulative Index to Nursing & Allied Health Literature from inception through 2006. Two independent reviewers identified articles, compared results, and settled differences through consensus. The Downs-Black scale was used to assess quality. Data included intervention type, patient numbers, demographics, study characteristics, instruments used, data compared, and outcomes reported. A random-effects meta-analysis combined amenable results.


RESULTS
Of 302 articles identified, 108 involved pharmacists' interventions; 36 addressed diabetes (14 medical clinics, 11 community pharmacies, 7 ambulatory care clinics, 4 hospital wards, 1 physician's office, 1 prison, and 3 in both medical clinics and community pharmacies; 1 did not describe its practice site). Research designs included randomized (n = 18) and nonrandomized (n = 9) controlled trials, pre- and postobservational cohorts (n = 2), retrospective cohort study (n = 1), chart reviews (n = 5), and database study (n = 1). Diabetes education (69%) and medication management (61%) were the most frequently used interventions. Mean +/- SD quality was 62 +/- 11% (fair). Fifty-one (69%) study results were sensitive. Meta-analysis of data from 2247 patients in 16 studies found a significant reduction in hemoglobin A1C (A1C) levels in the pharmacists' intervention group (1.00 +/- 0.28%; p < 0.001) but not in controls (0.28 +/- 0.29%; p = 0.335). Pharmacists' interventions further reduced A1C values 0.62 +/- 0.29% (p = 0.03) over controls.


CONCLUSIONS
A1C is sensitive to pharmacists' interventions. Several potentially sensitive outcomes were identified, but too few studies were available for quantitative summaries. More research is needed.
Machado
Márcio
M
Facultad de Ciencias Químicas y Farmacéuticas, Universidad de Chile, Santiago, Chile.
Bajcar
Jana
J
Guzzo
Giovanni C
GC
Einarson
Thomas R
TR
D001786:Blood Glucose / Q000378:metabolism; D001794:Blood Pressure / Q000502:physiology; D002986:Clinical Trials as Topic / Q000379:methods; D003920:Diabetes Mellitus / Q000097:blood / Q000453:epidemiology / Q000628:therapy*; D019468:Disease Management; D006801:Humans; D010353:Patient Education as Topic / Q000379:methods / Q000592:standards*; D010595:Pharmacists / Q000592:standards*; D024382:Professional Role; D012680:Sensitivity and Specificity; D016896:Treatment Outcome
D001786:Blood Glucose