Abstract
Review question/objective: The objective of this review is to determine the effects of pharmacist prescribing in the hospital setting.
More specifically, the objectives are to quantitatively analyze the effectiveness of pharmacist prescribing on patient outcomes, including, but not limited to, the reduction of error rates and adverse events related to medication prescription in patients who present to hospital, either in the inpatient or outpatient setting.
Background: For conditions that can be medically managed, diagnosis is followed by prescribing of medications to treat a condition or alleviate symptoms associated with it. Traditionally, the act of prescribing has been mainly associated with medical practitioners.
Non-medical prescribing is the extension of prescriptive rights provided to certain other professions apart from doctors, including nurses, pharmacists, optometrists and podiatrists. It was originally introduced to allow a more flexible system for the prescribing, supply and administration of medications in order to help improve patients' access to medications and ease the burden on general practitioners.1,2
Nurse prescribing was first introduced in the United States of America in 1969.3 In the last two decades, legislation changes have also occurred in various countries around the world to allow for non-medical prescribing.3-5
Pharmacist prescribing is currently legal in many countries, including Canada, New Zealand, the United Kingdom (UK) and the United States of America.2,6 In the UK, supplementary prescribing was first introduced in 2003, followed by independent prescribing in 2006.7
Different models of pharmacist prescribing have been described in the literature.1,5,6 They include independent, dependent and collaborative prescribing.
In independent prescribing, pharmacists are responsible for the assessment, diagnosis and clinical management of patients.
Dependent prescribing places more restrictions on the activity using protocols or formularies. The different types of dependent prescribing include:
* Prescribing by protocol: a written guideline (protocol) describes in explicit detail the activities that may be performed by the non-medical practitioner. This protocol includes the types of diseases and drug classes in which the practitioner may prescribe.
* Patient group directions: a written direction relating only to supply and administration of a prescription medicine.
* Prescribing by formulary: a limited list of medicines with limitations on prescribing.
* Prescribing by patient referral: patients are referred by a physician for specific drug therapy management or to achieve a defined therapeutic outcome.
* Repeat prescribing: medication-refill services in clinics for patients who require new continuing prescriptions prior to their next available appointment with their physician.
* Supplementary prescribing: a voluntary partnership between the physician and pharmacist, where the physician undertakes the initial assessment and the supplementary prescriber (pharmacist) prescribes in accordance with the care plan which has been agreed by the physician and patient.
In collaborative prescribing, there is a cooperative practice relationship between the pharmacist and physician, where the pharmacist may prescribe medications. The physician diagnoses and makes initial treatment decisions for the patient while the pharmacist selects, monitors, modifies, continues or discontinues the treatment as appropriate.
While systematic reviews on nurse prescribing are available,8,9 there are currently no systematic reviews available to quantify the effects of pharmacist prescribing in the hospital setting. One review published in 2011 assessed the contribution of prescribing by nurses and allied health professionals, but this was limited to the primary care setting.3 In 2004, a review focusing on pharmacist prescribing was published, and included prescribing in both the community and hospital setting.10 This review identified only four studies with an experimental design and concluded that additional research was needed to establish the validity of pharmacist prescribing.
In a review which evaluated the impact of pharmacists on mental health, some studies involving pharmacist prescribing were included but were not the main focus of the review.11 Other published reviews which have included pharmacist prescribing mainly relate to descriptions of its current practice (including existing policies and procedures) in a specific country or region, barriers to its successful implementation, or the perspectives of pharmacist prescribers, other healthcare professionals or patients on pharmacist prescribing.2,6,12 A systematic review on the effects of pharmacist prescribing on patient outcomes in the hospital setting is therefore warranted.
Article Content
Inclusion criteria
Types of participants
This review will consider studies that include patients in a hospital setting, including those admitted to hospital, those being assessed prior to elective admission, and those being assessed in outpatient clinics. Children and adults of all ages (i.e. from neonates to geriatrics), not limited to any specific medical condition or admission reason, who are prescribed medication(s) by a pharmacist, will be included in this review.
Types of intervention(s)/phenomena of interest
This review will consider studies that evaluate all forms of pharmacist prescribing in the hospital setting. The comparator will be usual care, i.e. prescriptions by hospital medical staff.
Types of outcomes
This review will consider any study that reported the effects of pharmacist prescribing on patient outcomes. A strict definition of outcome measures is not defined, but may include:
* Primary: error rates in prescriptions, including, but not limited to, medication administration errors of omission due to omission of the medicine from the medication chart; any measurable clinical outcomes such as adverse events, morbidity or mortality including therapeutic failure or therapeutic benefit.
* Secondary: change in number of medications on discharge, assessment of presence of drug interactions, requirement of change in prescription by medical prescriber following prescribing by pharmacist; other indirect outcomes related to satisfaction of patients or clinicians.
Types of studies
This review will consider any experimental study design including randomized controlled trials and quasi-experimental trials for inclusion. Studies with a qualitative design, publications not pertaining to primary research or papers published in languages apart from English will be excluded from the review. Studies with lower levels of evidence, such as non-randomized experimental trials or observational studies (analytic or descriptive) will also be considered and discussed narratively if the randomized controlled or quasi-experimental trials identified cannot be meaningfully combined in a meta-analysis due to heterogeneity or small subject numbers.
Search strategy
The search strategy aims to identify both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article.
A second search using all identified keywords and index terms will then be undertaken across all included databases. A combination of Medical Subject Headings (MeSH) and keywords will be used; text variations will be set out clearly in a logic grid to enable replicability of the search results.
Initial MeSH or keywords will include: pharmacist, pharmacy services, prescribing and hospitals.
The databases to be searched include: CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, Pubmed, Scopus and Web of Science. Studies published from database inception up until September 2015 will be considered for inclusion in this review. This is to ensure that all possible relevant studies are included as there is a huge variation in the dates that pharmacist prescribing was introduced in different countries.
Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Where required, the authors of potential studies to be included will be contacted and asked to provide further clarification on data to aid data extraction and analysis.
The search for unpublished studies will be undertaken using Google and MedNar.
Potential studies that have been identified will be imported into an Endnote database for management and duplicate references will be removed.
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data extraction
Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis
Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Conflicts of interest
The authors do not have any conflicts of interest with this research topic.
Acknowledgements
The author would like to acknowledge Selena Ooi for contributing her ideas and support for conducting this project
References
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