The Effectiveness of Pharmacist Interventions on Cardiovascular Risk: The Multicenter Randomized Controlled RxEACH Trial. A Markov model of the cost-effectiveness of pharmacist care for diabetes in prevention of cardiovascular diseases: evidence from Kaiser Permanente Northern California. Rationale and Design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study Effectiveness of Dader Method for pharmaceutical care on control of blood pressure and total cholesterol in outpatients with cardiovascular disease or cardiovascular risk: EMDADER-CV randomized controlled trial. Telemedicine cardiovascular risk reduction in veterans: The CITIES trial Interventions of Hospital Pharmacists in Improving Drug Therapy in Children Global Risk Assessment to Guide Blood Pressure Management in Cardiovascular Disease Prevention National Study of Physician Awareness and Adherence to Cardiovascular Disease Prevention Guidelines A randomized trial of the effect of community pharmacist intervention on cholesterol risk management: the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP). A randomized trial of a community-based approach to dyslipidemia management Assessment of clinical pharmacist management of lipid-lowering therapy in a primary care setting. Greater effect of enhanced pharmacist care on cholesterol management in patients with diabetes mellitus: a planned subgroup analysis of the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP). An integrated general practice and pharmacy-based intervention to promote the use of appropriate preventive medications among individuals at high cardiovascular disease risk: protocol for a cluster randomized controlled trial Effect of Collaborative Care for Depression on Risk of Cardiovascular Events: Data From the IMPACT Randomized Controlled Trial Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP): A Randomized Trial Design of the Effect of a Community Pharmacist Intervention Program on Serum Cholesterol Risk Physicians' perception, knowledge and awareness of cardiovascular risk factors and adherence to prevention guidelines: the PERCRO-DOC survey. Community pharmacy interventions for public health priorities: protocol for a systematic review of community pharmacy-delivered smoking, alcohol and weight management interventions The systematic coronary risk evaluation (SCORE) for the prevention of cardiovascular diseases. Does evidence exist for its effectiveness? A systematic review Evaluation of cardiovascular risk predicted by different SCORE equations: The Netherlands as an example Legacy Effect of Delayed Blood Pressure-Lowering Pharmacotherapy in Middle-Aged Individuals Stratified by Absolute Cardiovascular Disease Risk: Protocol for a Systematic Review A multifaceted quality improvement intervention for CVD risk management in Australian primary healthcare: a protocol for a process evaluation A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. Pharmacist-Led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared With Usual Care
BACKGROUND Despite the cardiovascular disease ( CVD ) risk associated with hypertension , diabetes , dyslipidemia , and smoking , these risk factors remain poorly identified and controlled . OBJECTIVES The study sought to evaluate the effectiveness of a community pharmacy-based case finding and intervention on cardiovascular risk . METHODS The RxEACH ( Alberta Vascular Risk Reduction Community Pharmacy Project ) study was a r and omized trial conducted in 56 community pharmacies . Participants were recruited by their pharmacist , who enrolled adults at high risk for CVD . Patients were r and omized to usual care ( usual pharmacist care with no specific intervention ) or intervention , comprising a Medication Therapy Management review from their pharmacist and CVD risk assessment and education . Pharmacists prescribed medications and ordered laboratory tests as per their scope of practice to achieve treatment targets . Subjects received monthly follow-up visits for 3 months . The primary outcome was difference in change in estimated CVD risk between groups at 3 months . CVD risk was estimated using the greater of the Framingham , International , or United Kingdom Prospect i ve Diabetes Study risk scores . RESULTS We enrolled 723 patients ( mean 62 years of age ; 58 % male , and 27 % smokers ) . After adjusting for baseline values and center effect , there was a 21 % difference in change in risk for CVD events ( p < 0.001 ) between the intervention and usual care groups . The intervention group had greater improvements in low-density lipoprotein cholesterol ( -0.2 mmol/l ; p < 0.001 ) , systolic blood pressure ( -9.37 mm Hg ; p < 0.001 ) , glycosylated hemoglobin ( -0.92 % ; p < 0.001 ) , and smoking cessation ( 20.2 % ; p = 0.002 ) . CONCLUSIONS The RxEACH study was the first large r and omized trial of CVD risk reduction by community pharmacists , demonstrating a significant reduction in risk for CVD events . Engagement of community pharmacists with an exp and ed scope of practice could have significant public health implication s. ( The Alberta Vascular Risk Reduction Community Pharmacy Project : RxEACH [ RxEACH ] ; NCT01979471 ) BACKGROUND It has been demonstrated in previous studies that pharmacist management of patients with type 2 diabetes mellitus ( T2DM ) in the outpatient setting not only improves diabetes-related clinical outcomes such as hemoglobin A1c but also blood pressure ( BP ) , total cholesterol ( TC ) , and quality of life . Improved control of BP and TC has been shown to reduce the risks of cardiovascular disease ( CVD ) , which has placed a heavy economic burden on the health care system . However , no study has evaluated the cost-effectiveness of pharmacist intervention programs with respect to the long-term preventive effects on CVD outcomes among T2DM patients . OBJECTIVES To ( a ) quantify the long-term preventive effects of pharmacist intervention on CVD outcomes among T2DM patients using evidence from a matched cohort study in the outpatient primary care setting and ( b ) assess the relative cost-effectiveness of adding a clinical pharmacist to the primary care team for the management of patients with T2DM based on improvement in CVD risks with the aid of an economic model . METHODS Clinical data between the periods of June 2007 to February 2010 were collected from electronic medical records at 2 separate clinics at Kaiser Permanente ( KP ) Northern California , 1 with primary care physicians only ( control group ) and the other with the addition of a pharmacist ( enhanced care group ) . Patients in the enhanced care group were matched 1:1 with patients in the control group according to baseline characteristics that included age , gender , A1c , and Charlson comorbidity score . The estimated 10-year CVD risk for both groups was calculated by the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) Risk Engine ( version 2 ) based on age , sex , race , smoking status , atrial fibrillation , duration of diabetes , levels of A1c , systolic BP ( SBP ) and TC , and high-density lipoprotein cholesterol ( HDL-C ) observed at 12 months . There was no statistical difference in the baseline clinical inputs to the Risk Engine ( A1c [ P=0.115 ] , SBP [ P=0.184 ] , TC [ P=0.055 ] , and HDL-C [ P=0.475 ] ) between the 2 groups . A Markov model was developed to simulate the estimated CVD outcomes over 10 years and to estimate cost-effectiveness . The final outcomes examined included incremental cost and effectiveness measured by life years and per quality -adjusted life year gained . Both deterministic sensitivity analysis ( SA ) and probabilistic SA were conducted to examine the robustness of the results . RESULTS The estimated risks for coronary heart disease ( CHD ) and stroke ( both nonfatal and fatal ) at the end of the follow-up were consistently lower in the enhanced care group compared with the control group , even though baseline risks in both groups were similar . The absolute risk reduction ( ARR ) between the enhanced care and control groups increased over time . For example , the ARR for nonfatal CHD risk in year 1 was 0.5 % ( 1.2 % vs. 0.7 % ) , whereas the ARR increased to 5.5 % in year 10 ( 14.8 % vs. 9.3 % ) . Similarly , the ARR between the enhanced care and the control groups was calculated as 0.3 % for fatal CHD in year 1 and increased to 4.6 % in year 10 . Results from the Markov model suggest that the enhanced care group was shown to be a dominant strategy ( less expensive and more effective ) compared with the control group in the 10-year evaluation period in the base-case ( average or mean results ) scenario . Sensitivity analysis that took into account the uncertainty in all important variables , such as wage of pharmacists , utility weight ( the degree of preference individuals have for a particular health state or condition ) , response rate to pharmacists ' care , and uncertainty associated with the estimated 10 years of CVD risk , revealed that the relative value of enhanced care was robust to most of the variations in these parameters . Notably , the level of cost-effectiveness measured by net monetary value depends on the time horizon adopted by the payers and the magnitude of CVD risk reduction . The enhanced care group has a higher chance of being considered as a cost-effective strategy when a longer time horizon such as a minimum of 4 to 5 years is adopted . CONCLUSIONS Adding pharmacists to the health care management team for diabetic patients improves the long-term CVD risks . The longer-term CVD risk reductions were shown to be more dramatic than the short-term reduction . A longer time horizon adopted by health plans in managing T2DM patients has a higher probability of making the intervention cost-effective Background —Medication errors and adverse drug events are common after hospital discharge due to changes in medication regimens , suboptimal discharge instructions , and prolonged time to follow-up . Pharmacist-based interventions may be effective in promoting the safe and effective use of medications , especially among high-risk patients such as those with low health literacy . Methods and Results —The Pharmacist Intervention for Low Literacy in Cardiovascular Disease ( PILL-CVD ) study is a r and omized controlled trial conducted at 2 academic centers — V and erbilt University Hospital and Brigham and Women 's Hospital . Patients admitted with acute coronary syndrome or acute decompensated heart failure were r and omly assigned to usual care or intervention . The intervention consisted of pharmacist-assisted medication reconciliation , inpatient pharmacist counseling , low-literacy adherence aids , and tailored telephone follow-up after discharge . The primary outcome is the occurrence of serious medication errors in the first 30 days after hospital discharge . Secondary outcomes are health care utilization , disease-specific quality of life , and cost-effectiveness .  Enrollment was completed September 2009 . A total of 862 patients were enrolled , and 430 patients were r and omly assigned to receive the intervention . Analyses will determine whether the intervention was effective in reducing serious medication errors , particularly in patients with low health literacy . Conclusions —The PILL-CVD study was design ed to reduce serious medication errors after hospitalization through a pharmacist-based intervention . The intervention , if effective , will inform health care facilities on the use of pharmacist-assisted medication reconciliation , inpatient counseling , low-literacy adherence aids , and patient follow-up after discharge . Clinical Trial Registration — clinical trials.gov . Identifier : NCT00632021 BACKGROUND Although some studies have demonstrated that pharmacist intervention can improve drug therapy among patients with cardiovascular disease ( CVD ) , more evidence derived from r and omized controlled trials ( RCTs ) is needed , including assessment of the effect of community pharmacist interventions in patients with CVD . OBJECTIVE To assess the effectiveness of the Dader Method for pharmaceutical care on achieving therapeutic goals for blood pressure ( BP ) , total cholesterol ( TC ) , and both BP and TC ( BP/TC ) in patients with CVD and /or high or intermediate cardiovascular ( CV ) risk attending community pharmacies in Spain . METHODS Patients aged 25 to 74 years attending community pharmacies with a prescription for at least 1 drug indicated for CVD or CV risk factors were r and omized to 2 groups : an intervention group that received pharmaceutical care , which was provided by specially trained pharmacists working in collaboration with physicians , and a control group that received usual care ( routine dispensing counseling ) and verbal and written counseling regarding CVD prevention .  Patients were recruited from December 2005 to September 2006 , and both groups were followed for 8 months . Study outcomes were assessed at baseline and at 16 and 32 weeks after r and omization . The primary outcome measures were the proportions of patients achieving BP , TC , and BP/TC therapeutic goals ( BP lower than 140/90 mm Hg for patients with uncomplicated hypertension and lower than 130/80 mm Hg for patients with diabetes , chronic kidney disease , or history of myocardial infa rct ion or stroke ; TC lower than 200 mg per dL for patients without CVD and lower than 175 mg per dL for patients with CVD ) . Secondary outcomes were mean BP and TC values . BP was assessed manually by the pharmacist after a 10-minute rest in the supine position . This measurement was performed twice for every participant , and the average of the 2 measurements was calculated . TC was measured by the pharmacist during the study visit using the enzymatic dry method . Statistical analyses were performed using 2-tailed McNemar tests , Pearson chi-square tests , and Student 's t-tests ; P < 0.05 was considered statistically significant . RESULTS 714 patients were included in the study ( 356 intervention , 358 control ) , and the mean [ SD ] age was 62.8 [ 8.1 ] years . The 2 groups were similar at baseline in clinical and demographic characteristics , including the proportion of patients at therapeutic goals for BP , TC , and BP/TC . After 8 months of follow-up , there were statistically significant differences in favor of pharmaceutical care in the proportions of patients who achieved therapeutic goals for BP ( 52.5 % vs. 43.0 % , P=0.017 ) , TC ( 56.5 % vs. 44.1 % , P=0.001 ) , and BP/TC ( 37.1 % vs. 21.8 % , P < 0.001 ) . CONCLUSION Compared with usual care plus written education , pharmaceutical care focused on patient evaluation and follow-up in collaboration with physicians improved the achievement of BP , TC , and BP/TC treatment goals in patients with CVD and /or high or intermediate CV risk attending community pharmacies in Spain Background : Comprehensive programs addressing tailored patient self‐management and pharmacotherapy may reduce barriers to cardiovascular disease ( CVD ) risk reduction . Methods : This is a 2‐arm ( clinical pharmacist specialist – delivered , telehealth intervention and education control ) r and omized controlled trial including Veterans with poorly controlled hypertension and /or hypercholesterolemia . Primary outcome was Framingham CVD risk score at 6 and 12 months , with systolic blood pressure ; diastolic blood pressure ; total cholesterol ; low‐density lipoprotein ; high‐density lipoprotein ; body mass index ; and , for those with diabetes , HbA1c as secondary outcomes . Results : Among 428 Veterans , 50 % were African American , 85 % were men , and 33 % had limited health literacy . Relative to the education control group , the clinical pharmacist specialist – delivered intervention did not show a reduction in CVD risk score at 6 months ( −1.8 , 95 % CI −3.9 to 0.3 ; P = .10 ) or 12 months ( −0.3 , 95 % CI −2.4 to 1.7 ; P = .74 ) . No differences were seen in systolic blood pressure , diastolic blood pressure , or low‐density lipoprotein at 6 or 12 months . We did observe a significant decline in total cholesterol at 6 months ( −7.0 , 95 % CI −13.4 to −0.6 ; P = .03 ) in the intervention relative to education control group . Among patients in the intervention group , 34 % received at least 5 of the 12 planned intervention calls and were considered “ compliers . ” A sensitivity analysis of the “ complier average causal effect ” of intervention compared to control showed a mean difference in CVD risk score reduction of 5.7 ( 95 % CI −12.0 to 0.7 ) at 6 months and −1.7 ( 95 % CI −7.6 to 4.8 ) at 12 months . Conclusions : Despite increased access to pharmacist re sources , we did not observe significant improvements in CVD risk for patients r and omized to the intervention compared to education control over 12 months . However , the intervention may have positive impact among those who actively participate , particularly in the short term Medicines ' management or pharmaceutical care in paediatric patients is particularly dem and ing , mainly because the majority of available drugs have been developed for use in adults . As a result , in children , drugs are often unlicensed or used off-label , suitable formulations or appropriate strengths are lacking , and drugs have to be extemporaneously prepared , liquids and injections diluted , and tablets split . These factors increase the likelihood of medication errors and may lead to a reduction in drug effect . Age-specific changes in pharmacokinetics and pharmacodynamics further complicate drug therapy in children . All these challenges provide unique opportunities for pharmacists to improve the quality of care for paediatric patients .We conducted a systematic literature review examining whether the interventions of hospital pharmacists improve drug therapy in children . Several medical and pharmaceutical data bases were search ed systematic ally to identify articles investigating  hospital pharmacists '  interventions that were intended to improve drug therapy in children . Inclusion criteria were English language , primary research papers and studies in which clinical pharmacists contributed directly to patient care . Exclusion criteria were review s , editorials , question naire studies , modelling studies , letters and studies only available in abstract form . This systematic search identified 18 articles documenting the role of a clinical hospital pharmacist in paediatric care . These articles were divided into the following groups based on study type : ( i ) studies documenting interventions made by pharmacists and their role in in patients ; ( ii ) articles presenting the outcomes of a satellite pharmacy ; and ( iii ) articles examining pharmacist involvement in paediatric outpatient clinics . No r and omised study comparing pharmacist interventions with st and ard care was found . In conclusion , although it was difficult to compare the various studies identified because of the different setting s , design , duration , size , methodology and definition , all these studies highlighted the importance of hospital pharmacists to medicines ' management in paediatric patients . On the basis of this review , we can conclude that pharmacist review ing of medication charts is very important in identifying medication errors ; hence , it is likely to be the most effective method of improving drug therapy in children Elevated blood pressure ( BP ) is a causal risk factor for cardiovascular disease ( CVD ) . Epidemiological analyses have established the grade d and continuous association between higher BP and CVD . Moreover , r and omized clinical trials among individuals with hypertension have demonstrated , in aggregate , a reduction in CVD events by 20 % , coronary heart disease ( CHD ) by 17 % , stroke by 27 % , and heart failure by 28 % for every 10 mm Hg systolic BP ( SBP ) lowering with medical therapy.1 Therefore , prevention , detection , treatment , and control of elevated BP , and its clinical correlate hypertension , is an important public health priority and a primary target for CVD prevention . Although national health surveys have demonstrated improvements in hypertension awareness and treatment , strategic opportunities to improve the efficiency and efficacy of applying BP-lowering therapy in patients most likely to benefit remain.2 Global CVD risk assessment , using multivariable prediction models that estimate absolute CVD risk from routinely measured clinical variables , has been promulgated in several CVD prevention guidelines for cholesterol management to target the most intensive preventive therapies to those at highest absolute CVD risk.3–5 Hypertension guidelines , however , have instead relied solely on isolated BP thresholds and BP goals to guide treatment initiation and intensity . In this review , we provide a rationale for incorporating global CVD risk assessment in BP treatment decision-making and propose a framework to guide its implementation in future CVD prevention guidelines . Epidemiological analyses have firmly established that CVD is a multifactorial condition and that modest increases of several CVD risk factors can often lead to greater overall risk than a severe elevation of a Background —Few data have evaluated physician adherence to cardiovascular disease ( CVD ) prevention guidelines according to physician specialty or patient characteristics , particularly gender . Methods and Results —An online study of 500 r and omly selected physicians ( 300 primary care physicians , 100 obstetricians/gynecologists , and 100 cardiologists ) used a st and ardized question naire to assess awareness of , adoption of , and barriers to national CVD prevention guidelines by specialty . An experimental case study design tested physician accuracy and determinants of CVD risk level assignment and application of guidelines among high- , intermediate- , or low-risk patients . Intermediate-risk women , as assessed by the Framingham risk score , were significantly more likely to be assigned to a lower-risk category by primary care physicians than men with identical risk profiles ( P<0.0001 ) , and trends were similar for obstetricians/gynecologists and cardiologists . Assignment of risk level significantly predicted recommendations for lifestyle  and preventive pharmacotherapy . After adjustment for risk assignment , the impact of patient gender on preventive care was not significant except for less aspirin ( P<0.01 ) and more weight management recommended ( P<0.04 ) for intermediate-risk women . Physicians did not rate themselves as very effective in their ability to help patients prevent CVD . Fewer than 1 in 5 physicians knew that more women than men die each year from CVD . Conclusions —Perception of risk was the primary factor associated with CVD preventive recommendations . Gender disparities in recommendations for preventive therapy were explained largely by the lower perceived risk despite similar calculated risk for women versus men . Educational interventions for physicians are needed to improve the quality of CVD preventive care and lower morbidity and mortality from CVD for men and women BACKGROUND Despite clear evidence for the efficacy of lowering cholesterol levels , there is a deficiency in its real-world application . There is a need to explore alternative strategies to address this important public health problem . This study aim ed to determine the effect of a program of community pharmacist intervention on the process of cholesterol risk management in patients at high risk for cardiovascular events . METHODS A r and omized controlled trial conducted in 54 community pharmacies ( 1998 - 2000 ) included patients at high risk for cardiovascular events ( with atherosclerotic disease or diabetes mellitus with another risk factor ) . Patients r and omized to pharmacist intervention received education and a brochure on risk factors , point-of-care cholesterol measurement , referral to their physician , and regular follow-up for 16 weeks . Pharmacists faxed a simple form to the primary care physician identifying risk factors and any suggestions . Usual care patients received the same brochure and general advice only , with minimal follow-up . The primary end point was a composite of performance of a fasting cholesterol panel by the physician or addition or increase in dose of cholesterol-lowering medication . RESULTS The external monitoring committee recommended early study termination owing to benefit . Of the 675 patients enrolled , approximately 40 % were women , and the average age was 64 years . The primary end point was reached in 57 % of intervention patients vs 31 % in usual care ( odds ratio , 3.0 ; 95 % confidence interval , 2.2 - 4.1 ; P<.001 ) . CONCLUSIONS A community-based intervention program improved the process of cholesterol management in high-risk patients . This program demonstrates the value of community pharmacists working in collaboration with patients and physicians Background : Dyslipidemia is an important risk factor for cardiovascular disease but is suboptimally managed . Pharmacists are accessible primary care professionals and with exp and ed scopes of practice ( including prescribing ) , could identify and manage patients with dyslipidemia . We sought to evaluate the effect of pharmacist prescribing of dyslipidemia medications on the proportion of participants achieving target LDL-cholesterol ( LDL-c ) levels . Methods : We conducted a r and omized controlled trial in 14 community pharmacies in Alberta , Canada . We enrolled adults with uncontrolled dyslipidemia as defined by the 2009 Canadian Dyslipidemia Guidelines . Intervention was pharmacist-directed dyslipidemia care , including assessment of cardiovascular risk , review of LDL-c , prescribing of medications , health behaviour interventions and follow-up every 6 weeks for 6 months . Usual care patients received their lipid results and a pamphlet on cardiovascular disease and usual care from their physician and pharmacist . Primary outcome was the proportion of participants achieving their target LDL-c ( < 2 mmol/L or ≥50 % reduction ) at 6 months between groups . Results : We enrolled 99 patients with a mean ( SD ) age of 63 ( 13 ) years , 49 % male and baseline LDL-c of 3.37 mmol/L ( 0.98 ) . Proportion of patients achieving LDL-c target was 43 % intervention versus 18 % control ( p = 0.007 ) . Adjusted odds of achieving target LDL-c were 3.3 times higher for the intervention group ( p = 0.031 ) , who also achieved greater reduction in LDL-c ( 1.12 mmol/L , SE = 0.112 ) versus control ( 0.42 mmol/L , SE = 0.109 ) , for an adjusted mean difference of 0.546 mmol/L ( SE = 0.157 ) , p < 0.001 . Conclusion : Pharmacist prescribing result ed in > 3-fold more patients achieving target LDL-c levels . This could have major public health implication BACKGROUND Pharmacists have been shown to positively impact the outcomes of care for treatment of many different kinds of disease states . In particular , pharmacist-run lipid clinics have enjoyed varying degrees of success , depending on the outcome assessed . At our hospital , when a patient is transferred to the pharmacist-coordinated lipid clinic , the primary care pharmacist is responsible for ordering and interpreting labs and prescribing and monitoring lipid-altering therapy . OBJECTIVE This study was design ed to assess if there is a statistically significant difference between the magnitude of serum cholesterol reduction for patients receiving lipid-altering pharmacotherapy  when clinical ly trained pharmacists are actively prescribing and adjusting the drug therapy compared to other health care practitioners ( usual care ) . METHODS Patient records from the hospital computer data bases were retrospectively and r and omly selected for analysis . Following evaluation for inclusion s and exclusions , 41 patient records remained for statistical analysis for the cohort group , and 47 records remained from the group of patients managed by a clinical pharmacist . RESULTS Management of dyslipidemia by a clinical pharmacist was associated with a significant reduction in overall mean low-density lipoprotein ( LDL , 18.5 % ) compared to the cohort that did not have a clinical pharmacist as the primary manager of dyslipidemia ( 6.5 % , P=0.049 ) . This suggests improved clinical outcomes , defined as greater LDL reduction , when clinical pharmacists participate in lipid management , including drug prescribing . The magnitude reduction in LDL was found to be related to the number of clinical pharmacy visits ( 11.4 % for 1 visit , 23.2 % for 2 visits , and 23.7 % for > 3 visits ) , compared to the usual care group ( -11.0 % , 18.0 % , and 7.4 % ; statistically significant , P=0.038 , for > 3 visits only ) . These results occurred even though the group of dyslipidemic patients managed primarily by a clinical pharmacist contained a statistically greater number of patients with 2 or more risk factors and high-density lipoprotein ( HDL ) levels less than 40 mg/dL. CONCLUSION Interdisciplinary medical teams that include clinical pharmacists who are actively prescribing and adjusting lipid drug therapy may achieve greater reductions in LDL for patients who have been assessed with multiple risk factors compared to patients managed without clinical pharmacists . Active participation by clinical pharmacists in lipid management for patients with elevated LDL result ed in improved treatment success as measured by the magnitude reduction in LDL . The reduction in LDL was between 5 % and 22 % per visit greater for patients being treated by clinical pharmacists versus usual care , even in a patient population with more risk factors . These intermediate outcomes may translate into long-term outcomes in fewer cardiovascular events , improved quality of life for patients with dyslipidemia , and lower costs associated with sequelae of dyslipidemias STUDY OBJECTIVE To determine the effect of enhanced pharmacist care on cholesterol management in patients with and without diabetes mellitus . METHODS We conducted a planned subgroup analysis of the Study of Cardiovascular Risk Intervention by Pharmacists ( SCRIP ) , a 54-center r and omized trial of pharmacist intervention compared with usual care in patients at high risk for cardiovascular events . The patients involved had atherosclerotic disease or diabetes . We compared the effect of pharmacist intervention in patients with and without diabetes . The primary end point was a composite of performing a fasting cholesterol profile , or adding or increasing the dosage of a cholesterol-lowering drug . Secondary end points were individual components of the primary end point and change in 10-year risk for cardiovascular events , using the Framingham risk equation . RESULTS Of the 675 patients enrolled in the SCRIP study , 294 ( 44 % ) had diabetes .  Enhanced pharmacist care had a more beneficial effect on cholesterol management in those with diabetes ( odds ratio [ OR ] 4.8 ) than without diabetes ( OR 2.1 ) , p=0.01 . Secondary end points showed similar trends , and reduction in Framingham risk was greater in patients with diabetes than without . CONCLUSION Pharmacist intervention for dyslipidemia appears to have a greater impact in patients with diabetes . Results of this sub study suggest that pharmacists should target this patient group for interventions in cholesterol risk management Background Cardiovascular diseases ( CVD ) are responsible for significant morbidity , premature mortality , and economic burden . Despite established evidence that supports the use of preventive medications among patients at high CVD risk , treatment gaps remain . Building on prior evidence and a theoretical framework , a complex intervention has been design ed to address these gaps among high-risk , under-treated patients in the Australian primary care setting . This intervention comprises a general practice quality improvement tool incorporating clinical decision support and audit/feedback capabilities ; availability of a range of CVD polypills ( fixed-dose combinations of two blood pressure lowering agents , a statin ± aspirin ) for prescription when appropriate ; and access to a pharmacy-based program to support long-term medication adherence and lifestyle modification . Methods Following a systematic development process , the intervention will be evaluated in a pragmatic cluster r and omized controlled trial including 70 general practice s for a median period of 18 months . The 35 general practice s in the intervention group  will work with a nominated partner pharmacy , whereas those in the control group will provide usual care without access to the intervention tools . The primary outcome is the proportion of patients at high CVD risk who were inadequately treated at baseline who achieve target blood pressure ( BP ) and low-density lipoprotein cholesterol ( LDL-C ) levels at the study end . The outcomes will be analyzed using data from electronic medical records , utilizing a vali date d extraction tool . Detailed process and economic evaluations will also be performed . Discussion The study intends to establish evidence about an intervention that combines technological innovation with team collaboration between patients , pharmacists , and general practitioners ( GPs ) for CVD prevention . Trial registration Australian New Zeal and Clinical Trials Registry Objective Although depression is a risk and prognostic factor for cardiovascular disease ( CVD ) , depression trials involving cardiac patients have not observed the anticipated cardiovascular benefits . To test our hypothesis that depression treatment delivered before clinical CVD onset reduces risk of CVD events , we conducted an 8-year follow-up study of the Indiana sites of the Improving Mood-Promoting Access to Collaborative Treatment ( IMPACT ) r and omized controlled trial . Methods Participants were 235 primary care patients 60 years or older with major depression or dysthymia who were r and omized to a 12-month collaborative care program involving antidepressants and psychotherapy ( 85 without and 35 with baseline CVD ) or usual care ( 83 without and 32 with baseline CVD ) . Hard CVD events ( fatal/nonfatal ) were identified using electronic medical record and Medicare/Medicaid data . Results A total of 119 patients ( 51 % ) had a hard CVD event . As hypothesized , the treatment × baseline CVD interaction was significant ( p = .021 ) . IMPACT patients without baseline CVD had a 48 % lower risk of an event than did usual care patients ( 28 % versus 47 % , hazard ratio = 0.52 , 95 % confidence interval = 0.31–0.86 ) . The number needed to treat to prevent one event for 5 years was 6.1 . The likelihood of an event did not differ between IMPACT and usual care patients with baseline CVD ( 86 % versus 81 % , hazard ratio = 1.19 , 95 % confidence interval , 0.70–2.03 ) . Conclusions Collaborative depression care delivered before CVD onset halved the excess risk of hard CVD events among older , depressed patients . Our findings raise the possibility that the IMPACT intervention could be used as a CVD primary prevention strategy . Trial Registration : clinical trials.gov Identifier : NCT01561105 OBJECTIVE : To determine the efficacy of a program of intervention by pharmacists on lipid risk management in patients at high risk for cardiovascular events . METHODS : R and omized , multicenter ( 44 sites in Alberta and Saskatchewan ) study of community pharmacist intervention versus usual care in 1000 patients . Patients are those at high risk of vascular events ( existing atherosclerotic vascular disease , or diabetes with ≥1 other risk factor ) . After obtaining consent , the pharmacist calls the Project Office to r and omize . Patients allocated to intervention receive a brochure and education about cardiovascular risk factors . Pharmacists also complete a physician contact form , which lists the patient 's risk factors , medications , and any recommendations . A point-of-care cholesterol test is performed , the result is discussed with the patient , and it is entered on the contact form . If appropriate , the patient is asked to see his or her primary care physician for further assessment and /or treatment , and the form is faxed to the physician . Patients are followed up at two , four , eight , 12 , and 16 weeks . During follow-up visits , pharmacists provide educational reinforcement and check for primary end point occurrence . Patients allocated to usual care receive the brochure only , with minimal follow-up . The primary end point is a composite of measurement of a complete lipid panel by the physician , or addition or modification of lipid-lowering drug therapy . Sub studies will evaluate economics ( third-party payer and pharmacy manager perspective ) , patient satisfaction , and quality of life . CONCLUSIONS : SCRIP ( Study of Cardiovascular Risk Intervention by Pharmacists ) is a unique ongoing trial that is evaluating a community pharmacist intervention design ed to optimize cholesterol risk management in patients at high risk for cardiovascular events BACKGROUND Cardiovascular diseases ( CVD ) are the major cause of premature death in the world . This study was design ed to examine the physicians ' knowledge and perception of CVD risk factors and perceived implementation of CVD prevention guidelines as well as barriers to their implementation . METHODS A question naire survey by face-to-face interviews was performed among 1382 r and omly selected physicians ( general practitioners/family medicine specialists , internists and cardiologists ) from different regions of Croatia . RESULTS Most physicians believe that guidelines are useful but only 56.9 % are really using some guidelines . 40.2 % favour Joint European guidelines . More primary care physicians use their own personal experience in prevention while internists and cardiologists tend more to use the guidelines . 80.6 % believe that they treat their patients with dyslipidemia well but only 53.3 % knew the LDL-cholesterol goal value for high-risk patients and only 56.2 % knew which HDL-cholesterol level is the marker of increased risk . Hypertension was perceived as the most important risk factor , particularly by primary care physicians , while cardiologists tend to favour diabetes . Although most physicians considered the lack of financial re sources as the main barrier in CVD prevention , at the same time most of them believe that it could primarily be improved by better patient education . CONCLUSIONS Although most physicians support the guidelines use , only half of them use them and in average their knowledge of guidelines is not satisfactory . This is , together with the lack of time and finances and perceived lack of patients ' awareness , probably one of the main causes why they do not manage risk factors better Background Community pharmacists can deliver health care advice at an opportunistic level , related to prescription or non-prescription medicines and as part of focused services design ed to reduce specific risks to health . Obesity , smoking and excessive alcohol intake are three of the most significant modifiable risk factors for morbidity and mortality in the UK , and interventions led by community pharmacists , aim ed at these three risk factors , have been identified by the government as public health priorities . In 2008 , the Department of Health for Engl and stated that ‘ a sound evidence base that demonstrates how pharmacy delivers effective , high quality and value for money services is needed ’ ; this systematic review aims to respond to this requirement . Methods / design We will search the data bases MEDLINE , Embase , CINAHL , PsycINFO , Social Sciences Citation Index , ASSIA , IBSS , Sociological Abstract s , Scopus and NHS Economic Evaluation Data base for studies that have evaluated interventions based on community pharmacies that aim to target weight management , smoking cessation and alcohol misuse . We will include all r and omised controlled trials ( RCTs ) , non-r and omised controlled trials ( N RCTs ) , controlled before-after studies ( CBAs ) and interrupted time series ( ITS ) and repeated measures studies . Data from included studies will be extracted by two independent review ers and will include study details methods , results , intervention implementation/costs and method ological quality . Meta- analysis will be conducted if appropriate ; if not , the synthesis will be restricted to a narrative overview of individual studies looking at the same question . Discussion The review aims to summarise the evidence base on the effectiveness of community pharmacy interventions on health and health behaviours in relation to weight management , smoking cessation and alcohol misuse . It will also explore if , and how , socio-economic status , gender , ethnicity and age moderate the effect of the interventions and will describe how the interventions included in the review have been organised , implemented and delivered , since context is an important factor governing the success of public health interventions . The findings from this review will have an impact on the commissioning of public health services aim ing to promote healthy weight , smoking cessation and prevent excessive alcohol consumption . Systematic review registration The review has been registered with PROSPERO ( registration no. CRD42013005943 ) . Available at : http://www.crd.york.ac.uk/ prospero /display_record.asp?ID = CRD42013005943 Objectives : The SCORE model predicts the ten-year risk of cardiovascular mortality but it is still unknown whether applying the SCORE in clinical practice subsequently improves cardiovascular disease ( CVD ) outcomes . The objective of this study is to assess the effect of total cardiovascular risk estimation using the SCORE in preventing serious cardiovascular events in European adults without prior CVD . Methods and results : Data sources : eight bibliographical data bases ( 2003 – August 2015 ) , other internet sources and reference lists of articles were checked . This was supplemented by contact with the board members of the European Society of Cardiology ( ESC ) and the authors of the SCORE model . Study eligibility criteria : all prospect i ve studies in any language investigating the effect of using the SCORE on the clinical outcome ( CVD death , major events and adverse outcomes ) in an adult population were examined . Two review ers assessed the studies independently ( titles , abstract s , full texts ) . After removal of duplicates , 5,256 records were screened and 14 full text papers considered . No eligible studies were identified . An extensive literature search revealed no r and omized control trial or other prospect i ve study comparing significant clinical outcomes between groups that used the SCORE and those who did not . Conclusions : The effect of using the SCORE ( with or without subsequent intervention ) on CVD death , all-cause mortality , major CVD events like myocardial infa rct ion and stroke , as well as adverse outcomes , is still unknown . A cluster r and omised controlled trial is warranted to evaluate the use of the SCORE on important outcomes Background In Europe , for primary prevention of cardiovascular diseases ( CVD ) , the Systematic COronary Risk Evaluation ( SCORE ) risk charts for high-risk and low-risk regions ( SCORE-high and SCORE-low , respectively ) are used . For the Dutch ‘ Clinical Practice Guideline for Cardiovascular Risk Management ’ an adapted SCORE risk chart ( SCORE-NL ) was developed in collaboration with the SCORE group . We evaluated these three SCORE equations using Dutch risk factor and mortality data . Design Prospect i ve cohort study with 10-year follow-up . Methods Baseline data were collected between 1987 and 1997 in 32 885 persons aged 37.5–62.5 years .  Vital status was checked and causes of death were obtained from Statistics Netherl and s. On the basis of the level of risk factors , the expected number of CVD deaths was calculated by applying the three SCORE equations and compared with the observed number . Results The observed CVD mortality was three-fold higher in men ( n = 242 ; 1.6 % ) than in women ( n = 83 ; 0.5 % ) . On the basis of SCORE-NL , 8.5 % of the men and 0.8 % of the women had a CVD mortality risk of 5 % or more . The ratio of the observed-to-expected number of CVD deaths was 0.75 for men and 0.55 for women using SCORE-NL , 0.54 and 0.56 using SCORE-high , and 1.11 and 0.95 using SCORE-low . Conclusion At the population level , SCORE-low predicts the number of CVD deaths well , whereas both SCORE-NL and SCORE-high overestimate the number of CVD deaths by a factor 1.5–2 Background Many national and international guidelines recommend that the initiation of blood pressure (BP)-lowering drug treatment for the primary prevention of cardiovascular disease ( CVD ) should no longer be based on BP level alone , but on absolute cardiovascular risk . While BP-lowering drug treatment is beneficial in high-risk individuals at any level of elevated BP , clinicians are concerned about legacy effects on patients with low-to-moderate risk and mildly elevated BP who remain “ untreated ” . Objective We aim to investigate the legacy effect of delayed BP-lowering pharmacotherapy in middle-aged individuals ( 45 - 65 years ) with mildly elevated BP ( systolic BP 140 - 159 mmHg and /or diastolic BP 90 - 99 mmHg ) stratified by absolute risk for primary prevention of CVD , but particularly in the low-risk ( < 10 % five-year absolute risk ) group . Methods R and omized trials of BP-lowering therapy versus placebo or pretreated subjects in active comparator studies with posttrial follow-up will be identified using a 2-step process . First , r and omized trials of BP-lowering therapy will be identified by ( 1 ) retrieving the references of trials included in published systematic review s of BP-lowering therapy , ( 2 ) retrieving studies published by the Blood Pressure Lowering Treatment Trialists ’ Collaboration ( BPLTTC ) , and ( 3 ) checking studies referenced in the 1993 World Health Organization/International Society of Hypertension meeting memor and um on BP management . Posttrial follow-up studies will then be identified by forward citation search ing the r and omized trials identified in step 1 through Web of Science . The search will include r and omized controlled trials with at least 1-year in-trial period and a posttrial follow-up phase . Age is the major determinant of absolute cardiovascular risk , so the participants in our review will be restricted to middle-aged adults who are more likely to have a lower cardiovascular risk profile . The primary outcome will be all-cause mortality . Secondary outcomes will include cardiovascular mortality , fatal stroke , fatal myocardial infa rct ion , and death due to heart failure . Results The search es for existing systematic review s and BPLTTC studies were piloted and modified . The study is expected to be completed before June 2018 . Conclusions The findings of this study will contribute to the body of knowledge concerning the beneficial , neutral , or harmful effects of delayed BP-lowering drug treatment on the primary prevention of CVD in patients with mildly elevated BP and low-to-moderate CVD risk . Trial Registration PROSPERO International Prospect i ve Register of Systematic Review s : CRD42017058414 ; https://www.crd.york.ac.uk/ PROSPERO /display_record.asp?ID = CRD42017058414 ( Archived by WebCite ® at http://www.webcitation.org/6t6sa8O2Q Background Cardiovascular disease ( CVD ) is the leading cause of death and disability worldwide . Despite the widespread availability of evidence -based clinical guidelines and vali date d risk predication equations for prevention and management of CVD , their translation into routine practice is limited . We developed a multifaceted quality improvement intervention for CVD risk management which incorporates electronic decision support , patient risk communication tools , computerised audit and feedback tools , and monthly , peer-ranked performance feedback via a web portal . The intervention was implemented in a cluster r and omised controlled trial in 60 primary healthcare services in Australia . Overall , there were improvements in risk factor recording and in prescribing of recommended treatments among under-treated individuals , but it is unclear how this intervention was used in practice and what factors promoted or hindered its use . This information is necessary to optimise intervention impact and maximally implement it in a post-trial context . In this study protocol , we outline our methods to conduct a theory-based , process evaluation of the intervention . Our aims are to underst and how , why , and for whom the intervention produced the observed outcomes and to develop effective strategies for translation and dissemination . Methods / Design We will conduct four discrete but inter-related studies taking a mixed methods approach . Our quantitative studies will examine ( 1 ) the longer term effectiveness of the intervention post-trial , ( 2 ) patient and health service level correlates with trial outcomes , and ( 3 ) the health economic impact of implementing the intervention at scale . The qualitative studies will ( 1 ) identify healthcare provider perspectives on implementation barriers and enablers and ( 2 ) use video ethnography and patient semi-structured interviews to underst and how cardiovascular risk is communicated in the doctor/patient interaction both with and without the use of intervention . We will also assess the costs of implementing the intervention in Australian primary healthcare setting s which will inform scale-up considerations . Discussion This mixed methods evaluation will provide a detailed underst and ing of the process of implementing a  quality improvement intervention and identify the factors that might influence scalability and sustainability . Trials registration 12611000478910 PURPOSE To assess the efficacy of a pharmacist-led , primary care-based , disease management program to improve cardiovascular risk factors and glycated hemoglobin ( A(1C ) ) levels in vulnerable patients with poorly controlled diabetes . METHODS A r and omized controlled trial of 217 patients with type 2 diabetes and poor glycemic control ( A(1C ) level > or=8.0 % ) was conducted at an academic general medicine practice from February 2001 to April 2003 . Intervention patients received intensive management from clinical pharmacists , as well as from a diabetes care coordinator who provided diabetes education , applied algorithms for managing glucose control and decreasing cardiovascular risk factors , and addressed barriers to care . Control patients received a one-time management session from a pharmacist followed by usual care from their primary care provider . Outcomes were recorded at baseline and at 6 and 12 months . Primary outcomes included blood pressure , A(1C ) level , cholesterol level , and aspirin use . Secondary outcomes included diabetes knowledge , satisfaction , use of clinical services , and adverse events . RESULTS For the 194 patients ( 89 % ) with 12-month data , the intervention group had significantly greater improvement than did the control group for systolic blood pressure ( -9 mm Hg ; 95 % confidence interval [ CI ] : -16 to -3 mm Hg ) and A(1C ) level ( -0.8 % ; 95 % CI : -1.7 % to 0 % ) . Change in total cholesterol level was not significant . At 12 months , aspirin use was 91 % in the intervention group versus 58 % among controls ( P < 0.0001 ) . Intervention patients had greater improvements in diabetes knowledge and satisfaction than did control patients . There were no significant differences in use of clinical services or adverse events . CONCLUSION Our comprehensive disease management program reduced cardiovascular risk factors and A(1C ) levels among vulnerable patients with type 2 diabetes and poor glycemic control Integration of clinical pharmacists in patient care may offer increased access to health care and improved patient outcomes . Recently introduced legislation would establish pharmacists as health care providers and enable coverage of pharmacists ' services through Medicare Part B in medically underserved communities ( 1 , 2 ) . Pharmaceutical care involves pharmacist collaboration with health team members to optimize therapeutic outcomes ( 3 ) . Since 1995 , the Department of Veterans Affairs has allowed clinical pharmacy specialists an exp and ed scope of practice , with independent prescribing privileges ( 4 ) . The scope of practice for clinical pharmacy specialists includes pharmaceutical care or comprehensive medication management for patients with chronic diseases in addition to less complex services , such as counseling patients on medications or responding to questions about drug information . A 2014 systematic review evaluated outpatient medication therapy management interventions ( 5 ) . Study inclusion criteria required that interventions have , at minimum , 3 elements : comprehensive medication review ; patient-directed education and counseling ; and coordination of care , including prescriber-directed interventions . The research ers concluded that evidence was insufficient for health outcomes , although interventions may reduce the frequency of some medication-related problems and decrease some health care use and costs . We determined the effectiveness and harms of pharmacist-led chronic disease management compared with usual care for community-dwelling adults . Chronic disease management is typically a multicomponent intervention ( Figure 1 ) , and we required that the pharmacist take a lead role in at least 1 component . Studies where the pharmacist was a collaborator on a Patient Aligned Care Team or similar care strategy were not included . This report summarizes findings of a Department of Veterans Affairs Evidence -based Synthesis Program review ( available at www.hsrd . research .va.gov/publications/esp ) . Figure 1 . Components of pharmacist-led chronic disease management . * Follow-up after prescription for medication effectiveness and safety and drug-related problems . Includes medication reconciliation . The pharmacist provides immunization , which was not an outcome of interest . Facilitate access to other health care professionals and provide education about disease , lifestyle changes , aspirin therapy , and tobacco cessation . Supplement . Study Protocol Methods We developed a protocol for the review with input from content experts and method ologists . The protocol was not registered but was available for comment during review development . Data Sources and Search es We search ed MEDLINE ( Ovid ) , CINAHL , the Cochrane Library , and International Pharmaceutical Abstract s from 1995 through February 2016 for English- language literature ( Appendix Table 1 ) . We obtained additional articles by h and - search ing reference lists of systematic review s and other articles and from peer- review ers . Appendix Table 1 . Search Strategy for MEDLINE ( Ovid ) Study Selection We focused on chronic disease management for out patients in health care facilities , excluding retail pharmacies . We emphasized patient- or health system-centered outcomes but also addressed intermediate measures . MEDLINE abstract s were review ed for eligibility by 2 research ers ; abstract s from other data bases were review ed by a single research er . Full-text articles of studies identified as potentially eligible on the basis of abstract review were obtained for further review . Each article was independently review ed by 2 investigators or research associates . We included studies of any design that had a control group , evaluated outpatient adults with or at risk for a chronic disease , tested an intervention where the pharmacist was responsible for a distinct component of patient care , and were set in U.S. health care facilities . We excluded studies that did not involve interventions intended to manage or prevent 1 or more chronic diseases and studies of anticoagulation clinics because pharmacist management is considered st and ard care in those setting s. The Appendix Figure shows the reasons for study exclusion at full-text review . Appendix Figure . Summary of evidence search and selection . CCT = controlled clinical trial ; IPA = International Pharmaceutical Abstract s ; RCT = r and omized , controlled trial . Data Extraction and Quality Assessment Study data were extracted by one investigator and independently verified by a second . Our main outcomes of interest were clinical events , mortality , patient satisfaction , health care utilization ( including urgent care or emergency department visits and hospitalizations ) , medication adherence , and goal attainment ( Appendix Table 2 ) We also assessed access to care , quality of life , drug-related problems , and costs . We assessed risk of bias ( low , medium , or high ) for individual studies on the basis of sequence generation , allocation concealment , confounding ( for nonr and omized studies ) , blinding , and incomplete or selective outcome reportinga modification of the Cochrane approach ( 6 ) ( Appendix Table 2 ) . Appendix Table 2 . Evidence From Included Studies Appendix Table 2Continued Appendix Table 2Continued Appendix Table 2Continued Data Synthesis and Analysis We grouped studies by disease state and described and qualitatively compared the characteristics and findings of included studies . We rated the overall strength of the body of evidence across disease states for clinical events , patient satisfaction , target goal attainment , urgent care or emergency department visits and hospitalizations , and medication adherence by using the method of Owens and colleagues ( 7 ) . Two trained review ers grade d the strength of evidence regarding the outcomes as high , moderate , low , or insufficient on the basis of risk of bias , consistency , precision , and directness . We resolved discrepancies in risk of bias and strength of evidence ratings by discussion with final determination arrived through consensus that included the principal investigator . Most findings are summarized in narrative form , but we pooled results if studies were r and omized ( noncluster ) trials and enrolled participants and outcome measures were similar within each disease condition . DerSimonianLaird r and om-effects models were used to calculate pooled risk ratios ( RRs ) and 95 % CIs . We assessed statistical heterogeneity by using the I 2 statistic ( 75 % indicates substantial heterogeneity ) ( 8) . Role of the Funding Source The Department of Veterans Affairs , Veterans Health Administration , Office of Research and Development , Quality Enhancement Research Initiative assigned the topic and review ed the key questions but was not involved in data collection , analysis , or manuscript preparation or su bmi ssion . Results Search results are shown in the Appendix Figure . We included 72 articles representing 63 studies ( 40 r and omized , controlled trials [ RCTs ] ) with 65 unique study population s ( 940 - 4172 - 7381 ) . We grouped studies by disease state of the population and study characteristics ( Table 1 ) . Most studies were conducted in primary care setting s ( community-based or university-affiliated ) , but a few were in specialty clinics ( cardiology , nephrology , endocrinology ) . Interventions were typically delivered by pharmacists in person or with a mix of in-person and remote visits ( in 89 % of studies ) over multiple sessions ( 89 % ) . However , interventions varied in composition , delivery mode , and intensity , making it difficult to identify important intervention characteristics . Fifty-two studies were judged as low or medium risk of bias . Table 1 . Summary of Included Studies , by Disease State and Study Characteristics * Studies were generally short term ( 12 months ) and had small sample s. They mainly assessed intermediate outcomes , such as blood pressure , cholesterol , or glucose goal attainment , in patients with hypertension , cardiovascular disease , or diabetes ( 45 of 65 unique studies ) . Goal attainment was listed as the primary study outcome in 23 unique studies . Clinical events were described in 15 unique studies and were the primary outcome in 2 of those studies . Office visits , medication adherence or nonadherence , hospitalizations , patient satisfaction , and health-related quality of life were noted in 26 , 27 , 20 , 19 , and 19 studies , respectively , but they rarely were the primary outcome . Additional study details are presented in Appendix Table 2 . Findings Across All Disease Conditions In 15 trials ( 12 RCTs ) reporting clinical events ( for example , hypotension or hypoglycemia requiring additional intervention ) , pharmacist-led care and usual care ( typically continuing a pre study visit schedule ) were generally similar ( Appendix Table 3 ) ( 12 , 14 , 1922 , 3437 , 59 , 62 , 64 , 71 , 75 , 77 ) Eight studies reported all-cause mortality  , of which 6 found similar mortality in the pharmacist-led care and control groups and 2 did not report significance ( 12 , 13 , 16 , 18 , 28 , 30 , 37 , 71 ) . One of these studies in patients with diabetes also reported no disease-related deaths ( 28 ) . However , of studies reporting clinical events or mortality , only 2 were design ed to assess clinical events ( 13 , 14 ) , outcomes were sporadically and inconsistently reported , and there were few events ( low strength of evidence ) ( Table 2 ) . Evidence was insufficient to evaluate the effect of pharmacist-led care on patient satisfaction ( overall and for each disease condition ) and limited reporting of quality -of-life outcomes . Compared with usual care , pharmacist-led care improved study -selected goal attainment ( typically for blood pressure , lipid , and glycemic goals ) . Strength of evidence was moderate , with consistent findings across disease conditions . Table 2 . Strength of Evidence , by Outcome Evaluated * Appendix Table 3 . Summary of Direction of Evidence For re source use outcomes , pharmacist-led care was similar to usual care for incidences or rates of office visits ( 26 studies ) , urgent care or
Pharmacist-directed care or in collaboration with physicians or nurses improve the management of major CVD risk factors in out patients
BACKGROUND Pharmacists may improve the clinical management of major risk factors for cardiovascular disease ( CVD ) prevention .
A systematic review was conducted to determine the impact of pharmacist care on the management of  CVD risk factors among out patients .