The impact of clinical pharmacist services on patient health outcomes in Pakistan: a systematic review

Ahmed et al. BMC Health Services Research https://doi.org/10.1186/s12913-021-06897-0 (2021) 21:859 RESEARCH Open Access The impact of clinical pharmacist services on patient health outcomes in Pakistan: a systematic review Ali Ahmed1*, Muhammad Saqlain2, Maria Tanveer2, Ali Qais Blebil1, Juman Abdulelah Dujaili1 and Syed Shahzad Hasan3 Abstract Background: The pharmacist’s role shifts from dispensing to bedside care, resulting in better patient health outcomes. Pharmacists in developed countries ensure rational drug use, improve clinical outcomes, and promote health status by working as part of a multidisciplinary team of healthcare professionals. However, clinical pharmacist services on healthcare utilization in low-and middle-income countries (LMICs) like Pakistan are unclear. As a result, we aim to systematically review pharmacists’ clinical roles in improving Pakistani patients’ therapeutic, safety, humanistic, and economic outcomes. Methods: We searched PubMed, Scopus, EMBASE, CINAHL, and Cochrane Library for relevant articles published from inception to 28th February 2021. All authors were involved in the screening and selection of studies. Original studies investigating the therapeutic, humanistic, safety, and economic impact of clinical pharmacists in Pakistani patients (hospitalised or outpatients) were selected. Two reviewers independently assessed the risk of bias in studies, and discrepancies were resolved through mutual consensus. All of the included studies were descriptively synthesised, and PRISMA reporting guidelines were followed. Results: The literature search found 751 articles from which nine studies were included; seven were randomized controlled trials (RCTs), and two were observational studies. Three RCTs included were having a low risk of bias (ROB), two RCTs were having an unclear ROB, while two RCTs were having a high ROB. The nature of clinical pharmacist interventions included one or more components such as disease-related education, lifestyle changes, medication adherence counselling, medication therapy management, and discussions with physicians about prescription modification if necessary. Clinical pharmacist interventions reduce medication-related errors, improve therapeutic outcomes such as blood pressure, glycemic control, lipid control, CD4 T lymphocytes, and renal functions, and improve humanistic outcomes such as patient knowledge, adherence, and health-related quality of life. However, no study reported the economic outcomes of interventions. Conclusions: The findings of the studies included in this systematic review suggest that clinical pharmacists play important roles in improving patients’ health outcomes in Pakistan; however, it should be noted that the majority of the studies have a high risk of bias, and more research with appropriate study designs is needed. Keywords: Low-and middle-income countries, Pharmacoeconomics, Pharmaceutical care, Therapeutics, Humanistic, Clinical * Correspondence: 1 School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500 Subang Jaya, Selangor, Malaysia Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ahmed et al. BMC Health Services Research (2021) 21:859 Background Since 1990, with pharmaceutical care introduction, pharmacists’ careers have evolved from single dispensary positions to patient-oriented health care [1, 2]. In developed countries, pharmacists are sufficiently trained to play a vital role in pharmaceutical care [3, 4]. However, in developing countries, pharmacists’ roles are gradually shifting toward ward rounds with other health professionals to monitor the patient’s progress, drug-related issues and communicate a medication therapy management plan [5– 7]. Meanwhile, they continue to be primarily responsible for manufacturing, distributing, and dispensing medicines [3, 8]. Clinical pharmacists can offer patients a wide range of services, including prescription drugs and healthrelated services [9, 10]. They can assist physicians in prescribing drugs rationally, ensuring that patients understand the dosage regimen and method of administration, and improving patient adherence [11]. Moreover, pharmacists play an important role in public health promotion at community pharmacy settings, such as tobacco and alcohol control, nutrition and a healthy lifestyle, routine immunisation, infection prevention and treatment, and the management of mental health and other chronic disease care [12–14]. According to the World Health Organization’s (WHO) data repository on the Pakistan health force, the pharmacist ratio per 10,000 population in 2019 was 1.545 [15]. Currently, over 3000 pharmacists in Pakistan receive Doctor of Pharmacy (Pharm D) degrees each year from 21 public and 25 private universities [16]. Moreover, as of 2019, the number of community pharmacies in Pakistan has increased to more than 40,000 [17]. To improve the regulation of medicines across the country, the Federal Government of Pakistan has established a regulatory body, the drug regulatory authority of Pakistan (DRAP) Act 2012 [18, 19]. Under the Act, regulations range from existing basic services (i.e., dispensing, procurement, storage, distribution of therapeutic products and counselling) to enhanced medicine services (pharmaceutical care, pharmacovigilance, pharmacoepidemiology, pharmacoeconomic and services offered at drug information and poison centres) at all levels such as pharmacy, clinical, hospital, and community levels [19, 20]. In 2014, to strengthen pharmacists’ expertise in clinical roles, the higher education commission (HEC) introduces the Department of Pharmacy Practice in Pakistan’s private and public sector universities [21]. As a result, studies in Pakistan have begun to highlight potential clinical pharmacy progress, including further bedside activities, patient consultation, and therap (...truncated)