Educación Ambiental en los centros escolares de la zona de estudio

With the role of pharmacists expanding to take on more advanced clinical roles another Cochrane review, this time conducted by Nkansah et al. (2010), focused on health-related outcomes of newly implemented clinical pharmacy interventions (such as medication counselling and optimisation services). However, the authors found that improvements in clinical outcomes (i.e. improvements in blood pressure, cholesterol levels, asthma score, etc.) as a result of pharmacist interventions were not always statistically significant and importantly had little (if any) explicit focus on the collaborative aspect of interventions. As a follow-up to this study, Geurts et al. (2012) undertook a systematic review that primarily focused on medication review and reconciliation that were carried out through the cooperation of pharmacists and GPs. Some 83 studies were included in the review which varied in terms of the interprofessional interventions assessed as well as in the rigour of the studies. Although many of the included studies reported positive outcomes in terms of patient satisfaction and the resolution of drug-related problems, just three of these studies (Makowsky et al., 2009a; Roughead et al., 2009; Roughead et al., 2011) reported significant improvements in objective outcomes such as hospital (re)admissions, and these had a low certainty of evidence. One of these studies was conducted by Makowsky et al. (2009a) who undertook a multicentre, quasi-randomised, controlled clinical trial where 220 patients received ‘team care’ through proactive clinical pharmacist services (medication history, patient-care during participation in rounds, resolution of drug-related issues, and discharge counselling) versus 231 patients that received standard care. They found that team care patients experienced fewer readmissions at 3 months (36.2% vs. 45.5%) but not at 6 months.

Another study conducted by Roughead et al. (2009) reviewed the impact of collaborative GP–pharmacist home medication reviews on time until the next hospitalisation in patients with heart failure in Australia. Here an intervention group received a service that included a GP referral, a home visit by an accredited pharmacist to identify medication‐related problems, a pharmacist report with follow‐up undertaken by the GP. In total 273 patients received the collaborative home medication review service and 5444 did not. Unadjusted results showed a 37% reduction in rate of hospitalisation for heart failure at any time and adjusted results showed a 45% reduction among those who had received a home medicines review compared with the unexposed patients. Whilst there was a reduction in patient hospitalization, the collaborative interprofessional nature of the interventions was unclear as it seemed to represent a care schedule that had side-by-side input from two professions rather than them collaboratively working together for the patient.

Roughead later repeated this study but this time reviewed the impact of GP–pharmacist collaborative home medication reviews on bleeds that led to hospitalisation in patients on warfarin (Roughead et al., 2011). The intervention once again represented a loose definition of collaborative working with HCPs working side-by-side rather than collaboratively. Here the 816 patients who received the home service were compared with 16,320 who did not. They found a 79% reduction in risk of hospitalisation for bleeding between 2 and 6 months, however this was not sustained over time (adjusted results).

A number of further RCTs and reviews of RCTs have been conducted related to a range of ‘collaborative’ pharmacist interventions. However, many of these studies lack explicit descriptions of the collaborative nature of the interventions. The descriptions often excluded the frequency, mode (face-to-face, by phone, written, etc.) and content of interprofessional interactions making it unclear as to whether true interprofessional collaborative working (where HCPs worked together to achieve improved outcomes) had occurred or whether the collaboration was simply the transfer of information between professionals. Furthermore, it was often the case that the trials compared a service conducted by another HCPs (absent of a pharmacist) with a pharmacist intervention that was classed as ‘collaborative’ due to the requirement for the pharmacist to inform another HCPs of the action or decision they had taken. Nevertheless, a number of studies discussed below concluded that having pharmacists make interventions in collaboration with other HCPs could benefit a range patient outcomes.

One of these studies was an RCT conducted by Tsuyuki et al. (2016) which highlighted that a community pharmacists’ cardiovascular disease (CVD) intervention comprising of a Medication Therapy Management review from their pharmacist and CVD risk assessment and education (predominantly conducted solely by the pharmacists apart from when communicating with doctors following each patient contact – when first conducting pharmacist CVD intervention then at a three month review) significantly reduced the risk for CVD events (adjusted value of 21% reduction). A similar finding was reported in an earlier study by Tsuyuki et al. (2002) which assessed pharmacists’ role in the management of cholesterol. This study found that such were the improvements in patients’ cholesterol from the intervention (where it was stated that community pharmacists provided education, management and referral to GPs) the study was ended early to fully incorporate the intervention into practice, however once again the ‘collaborative’ nature of this involved a simple referral to GPs for further management.

A similar theme was observed across a number of systematic reviews of RCTs featuring pharmacist led interventions, including a review of pharmacist care in heart failure (HF) by Koshman et al. (2008), in management of dyslipidemia by Charrois et al. (2012) and blood pressure (BP) control by Santschi et al. (2014). It was concluded across these reviews that pharmacists’ working collaboratively with other HCPs had a positive impact on patient outcomes, however it must be noted that these conclusions were often based on studies where there was no explicit comparison of interventions that were delivered solely by the pharmacist versus those that featured collaborative pharmacist-HCP interventions, where some comparison did occur there was no significant difference in outcomes, and the term ‘collaboration’ was rarely explicitly defined with many often seeing collaboration as information transfer between HCPs.

In one study Lalonde et al. (2011) aimed to explore the views of patients and doctors on pharmacists’ engaging with doctors in the collaborative management of patients with dyslipidaemia. Whilst patients felt they received better follow-up care when pharmacist were involved in their care and doctors felt the collaborative management of patients’ cholesterol was safe and effective, doctors were concerned that shifting some of the management activities to pharmacists may negatively impact their own relationship with the patient highlighting a potential issue with pharmacist-doctor interprofessional collaboration. A number of other studies also highlighted potential issues with pharmacist collaborative practice, one of which was an RCT conducted by Bryant et al. (2011) in New Zealand where authors compared a control group with patients receiving a clinical medication review conducted by community pharmacists in collaboration with GPs (pharmacists met with the patient’s GP to discuss recommendations about possible medicine changes) which was followed-up 3-monthly. The authors found that although medication reviews helped improve medication appropriateness, patients’ quality of life in the domains of emotional role and social functioning were seen to decrease significantly. Authors suggested that this may have been because participants possibly felt abandoned as 27 out of 44 pharmacists either withdrew or did not start the study citing time commitments required to conduct the intervention/study. Authors additionally concluded that the lack of community pharmacist participation suggested that community pharmacies may not be the appropriate environment in which to expand collaborative clinical medication reviews within primary care.

Furhtermore, a number of other RCTs which explored joint pharmacist-doctor care found that these collaborative care methods had no improvement on a number of patient outcomes. For example in an RCT conducted by Holland et al. (2005) in the UK authors found that a pharmacist led home based medication review service (which included two home visits by a pharmacist within two weeks and eight weeks of discharge to educate patients and carers about their drugs, remove out of date drugs, inform general practitioners of drug reactions or interactions, and inform the local pharmacist if a compliance aid is needed) had no improvement on quality of life and in fact increased hospital admissions compared to the patients not receiving the service. Of note, the interprofessional nature of the service here simply involved information transfer to GPs regarding drug reactions and interactions rather than a truly collaborative service. In addition, another UK based RCT conducted by Richmond et al. (2010) recruited 760 patients across 24 GP practices to compare usual care with those receiving collaborative pharmaceutical care undertaken by community pharmacists who interviewed patients, developed and implemented pharmaceutical care plans together with the patient’s GP, and thereafter undertook monthly medication reviews (both pharmacists and GPs attended training before the intervention). The study found that the intervention did not lead to any statistically significant change in the appropriateness of prescribing or health outcomes. Furthermore, in a similar RCT conducted by Sellors et al. (2003) in Canada comparing usual care with interventions where pharmacists conducted face-to-face medication reviews with the patients and then gave written recommendations to doctors to resolve any drug-related problems, found that although doctors accepted pharmacist recommendations, no significant improvements in patient outcomes or medication costs were observed.

With the literature evidencing the benefits of pharmacists collaborative practice having equivocal results, a low certainty of evidence and a lack of clarity related to the extent of the collaborative nature of each intervention, further work is needed to help evidence the value of interprofessional interactions involving pharmacists on patient outcomes.