ReviewExpanding the role of community pharmacists: Policymaking in the absence of policy-relevant evidence?
Introduction
The increasingly orthodox approach to formulating policies is to “do what the science says.” Many now believe that policy-making should be evidence-based in order to remove its “political” components [1]. The principle of evidence-based policymaking has indeed permeated all areas of public policy, including the health sector [2].
The increasing interest in evidence-based policymaking has implications for the community pharmacy profession. Recently, experts from academia and professional organizations have advocated in favour of devising policies to equip community pharmacists with expanded roles and responsibilities [3], [4]. Several international and national reviews on the role of community pharmacists have concluded that pharmacists could adopt an expanded, patient-centered role and could contribute to safe, effective and economic use of drugs [5], [6].
Triggering this patient-focused role two decades ago, Hepler and Strand defined pharmaceutical care as “the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life” [7]. Going beyond pharmaceutical care, Holland and Nimmo defined the Total Pharmacy Care Model as the combination of five existing practice models: drug information, self-care, clinical pharmacy, pharmaceutical care, and distribution [8]. As such, total pharmacy care is “the delivery of a comprehensive range of services that result in the maximum possible contribution to the health of a nation's population within the limits of the health care delivery structure.”
Indeed, community pharmacists have the potential to improve patients’ outcomes and reduce the costs of care by promoting health, preventing illness and avoiding adverse events [9]. Pharmacists are the third largest health care professional group in the world after physicians and nurses [10]. Community pharmacists are at times patients’ first and only contact with the health care system [11] and are often described as the most accessible of all health professionals [12]. Consequently, patient-centered responsibilities would be commensurate with the profession's extensive training and expertise.
Some governments appear to share the enthusiasm for expanding the role of community pharmacists. Across a number of countries, the emerging (albeit slowly) comprehensive role for community pharmacists implies a reconfiguration of the role of community pharmacists within the health system (see Fig. 1). With this understanding, pharmacists’ existing responsibilities towards patient welfare serve as a basis for policies, which grant them greater oversight over the proper and cost-effective use of medicines. The expectation is that, taken together, these activities will encourage care delivery that is coordinated across the health system. This will help to reduce drug-related adverse events and complications associated with long-term chronic conditions (e.g., cardiovascular disease and diabetes). In turn, it should also minimize office visits, hospitalizations and readmissions, and emergency department visits, all of which have considerable economic, clinical, and humanistic consequences.
Although expanding the role of community pharmacists is becoming an important policy objective, the evidence base for such policies has not been comprehensively evaluated. Numerous systematic reviews exist but whether these are adequate for policymaking is not clear. Distinguishing between evidence that is experimental in nature and evidence that is relevant for policymaking, it is important to assess the policy-relevance of the existing evidence on the basis of both its internal validity (“trustworthiness”) and external validity (“transferability”).
Our paper is consequently guided by the following research question: What is the policy-relevant evidence base in support of the new expanded roles for community pharmacists advocated by academics, professional organizations, and governments? To address this research question, we first briefly review the emerging comprehensive roles and responsibilities advocated by academic experts, professional organizations, and governments. We then critically review the scope, quality, and relevance of the corresponding systematic review evidence currently available to inform such policies.
In the next section, we outline the methods used to identify the relevant policy materials and corresponding systematic review evidence. In the third section, we report the findings of our review of systematic reviews and highlight the variability across reviews in terms of their findings. As we discuss in the final section of the paper, the drawbacks of most existing reviews raise an important question: should the pharmacy profession only undertake tasks for which there is strong policy relevance with evidence of economic and public health benefits?
Section snippets
Methods
First, we performed a review of academic publications as well as policy documents from governmental agencies and professional associations. The objective of this non-systematic, exploratory review was to compile a list of new roles and responsibilities for community pharmacists across Europe and North America. This was based on reviewing the Pharmaceutical Care and Total Pharmacy Care models, and searching governmental agency and professional association websites [17], [18], [19], [20], [21].
Results
Table 1 provides a list of expanded roles and responsibilities of community pharmacists as identified in governmental and professional association publications, and categorized to reflect the Pharmaceutical Care and Total Pharmacy Care models. Within this expanded role, community pharmacists have two primary objectives: (1) to encourage the effective, safe and appropriate use of medicines and (2) to promote the prevention and management of chronic diseases. This expanded role involves
Discussion
In this study, we reviewed the systematic review evidence in support of policy developments in expanding the role of community pharmacists. We included 33 systematic reviews of the literature published since 2000. According to some reviews, community pharmacists were highly effective in promoting the effective, safe, and appropriate use of medicines. According to others, the findings were either inconsistent or inconclusive with no clear implications for expanding the role of community
Conclusions
Scientific evidence is essential for informing health policy decisions. The notion of evidence-based policymaking has important implications for the community pharmacy profession as it is moving towards a more patient-centered role. A number of countries are introducing policies to formally expand the role played by community pharmacists in their respective health systems. The systematic review evidence in support of this transformation is mixed and inconclusive. Moreover, there are important
References (85)
- et al.
The evidence-based approach in health policy and health care delivery
Social Science & Medicine
(2000) - et al.
The corporatization of community pharmacy: implications for service provision, the public health function, and pharmacy's claims to professional status in the United Kingdom
Research in Social and Administrative Pharmacy
(2009) - et al.
Can clinical pharmacy services have a positive impact on drug-related problems and health outcomes in community-based older adults?
American Journal of Geriatric Pharmacotherapy
(2004) - et al.
Effect of pharmacist intervention on glycemic control in diabetes
Diabetes Research and Clinical Practice
(2011) - et al.
Polypharmacy in elderly patients
American Journal of Geriatric Pharmacotherapy
(2007) - et al.
Use of medications and polypharmacy are increasing among the elderly
Journal of Clinical Epidemiology
(2002) - et al.
Drug-related morbidity and mortality: updating the cost-of-illness model
Journal of the American Pharmaceutical Association
(2001) - et al.
Evidence based policy: proceed with care. Commentary: research must be taken seriously
BMJ
(2001) - et al.
A review of pharmaceutical care in community pharmacy in Europe
Harvard Health Policy Review
(2006) Professionalism and liberalisation
EuroPharm Forum
(2010)