The evolution of pharmacy practice research–Part I: Time to implement the evidence†

In this editorial series, we have brought together two leading pharmacy research journals, The International Journal of Pharmacy Practice and The Canadian Pharmacists Journal to take stock of the current evidence on the effectiveness of pharmacists’ contribution to patient care and make recommendations for future areas of research. The role of pharmacists has been changing globally over the past 30 years, moving away from a technical dispensing role to a more holistic cognitive role which begins to optimise the use of the full range of pharmacist competences acquired during basic and advanced training. The drivers for this change are multifactorial but include the increasing needs and demands of an ageing population, sustainability of the traditional physician–nurse-led healthcare workforce, increasing use of pharmacological approaches as the mainstay of disease management and need to increase the efficient and effective use of healthcare budgets. Underlining the direction of the change has been evidence derived from research studies confirming that the care provided by pharmacists is generally equivalent to and sometimes better than usual care. A recently published Cochrane review concluded that ‘Some services provided by pharmacists can have positive effects on patient health, including improved management of blood pressure and physical function’ whilst emphasising the challenges from the heterogeneity of the identified studies and risk of bias in some.[1] Similarly another Cochrane review focusing solely on hypertension concluded that ‘pharmacist led care may be a promising way of improving control in patients with hypertension, with the majority of RCTs being associated with improved blood pressure control, improved systolic blood pressure and more modestly improved diastolic blood pressure, but these interventions require further evaluation’.[2] Likewise, Santschi et al.[3] showed an average reduction of 7.6/3.9 mmHg over 39 trials of pharmacist care versus usual care. Finally a third Cochrane review on prescribing by other healthcare professionals concluded that ‘With appropriate training and support, nurses and pharmacists are able to prescribe medicines as part of managing a range of conditions to achieve comparable health management outcomes to doctors’.[4] The body of research exploring the expanded scope of pharmacy practice is large, but as the Cochrane reviews and others have highlighted, many reports are small-scale non-randomised studies or when a randomised controlled trial is reported there is insufficient detail of the intervention per se, or its implementation to allow replication or to make definitive recommendations. Nonetheless, across this diverse and heterogeneous literature, there is little to suggest that when pharmacists take on roles previously delivered by another healthcare professional, outcomes are worse than before; indeed, they are often better. Therefore, it is not surprising that in some countries, notably the UK and Canada, and to a lesser extent the United States and Australasia, pharmacists are increasingly recognised as integral to the core healthcare team, delivering frontline ‘first port of call’ and supportive services. Given the strong evidence for pharmacist care on improving patient outcomes, it follows that the next step is to apply this knowledge to our patient care in all jurisdictions. Stated another way, what all patients need is to be able to receive a full scope of pharmacist care (Figure 1).[5] Full scope of pharmacist care means these core services: injections, prescribing, laboratory testing and disease management.[5] However, such services are not widely available due to lack of implementation and health system failures, including restrictive legislation governing scope of practice. But, shouldn’t a full scope of pharmacist practice be defined by evidence, rather than outdated legislation? And not just in certain jurisdictions, this should be the universal standard for scope of core pharmacy practice. Components of a full scope of pharmacy practice (Reproducd with permission from Tsuyuki et al. [5]). Given the above, it is our societal duty to promote the delivery of the full scope of pharmacist care to all populations. Furthermore, extending capacity within healthcare teams by allowing pharmacists to deliver their full range of professional competences will improve access to care internationally. Pharmacists are the experts in medicines, and adding this specific expertise in medicines and their use to their generic healthcare skills means they uniquely contribute to patient care. To achieve our vision for pharmacy, we need to better understand how to achieve successful organisational change when extending the role of pharmacists in a meaningful and integrated way. In many countries, for example some European countries, pharmacy colleagues are delivering a wide range of services but these are in parallel to the mainstream healthcare service. These services are often only available on a private basis or are dependent on final medical sign off. We need implementation and integration of the full scope of autonomous practice which we know works. We do not need more small studies, often mistakenly labelled as pilot studies, nor obsequious surveys of what pharmacists and physicians think, unless these are informing subsequent implementation plans. Further, we should not spend precious and scarce health services research money on more trials repeating what has already been done, perhaps with only a subtle change of context. The priority for funding and pharmacy health service research should be on implementation science. We need to be bold and resolute. We might not get it perfect the first time (as pharmacists are wont to do), but it is better than the status quo and it moves us forward. Do what patients need and want – give them the full scope of pharmacist practice. Remember our societal responsibility. History will judge us on what we do now – either be at the forefront of patient care or fade into an irrelevant oblivion. Your choice.

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