Community pharmacist-led interventions, cardiovascular disease and medication adherence: a systematic review of randomised controlled trials
Authors: Al-Arkee S , Al-Ani O 
Published: April 2022

Abstract

Introduction
Medication adherence rates of preventative medication for cardiovascular disease (CVD) have been reported as 57% (1). Interventions to tackle nonadherence are important for improving health-related outcomes. Pharmacist-led interventions may have the potential to improve medication adherence and clinical outcomes in patients with CVD.

Aim
This study aimed to assess the impact of community pharmacist-led interventions on improving medication adherence and clinical outcomes in patients with CVD. This review also explores the characteristics of the interventions and the actual content of the interventions.

Methods
This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (2). The protocol was registered in the PROSPERO database (CRD42021250361). Four electronic databases (MEDLINE (Ovid), PubMed Central, PsycINFO (Ovid), and Cochrane library) were systematically searched for randomised controlled trials (RCTs), assessing the impact of pharmacist-led interventions on medication adherence in patients in CVD. RCTs were filtered for English language from inception to April 2021 and duplicate removed. Screening and selection of titles, abstracts, and full text was followed by data extraction and risk of bias assessed using the Cochrane Risk of Bias tool. A narrative synthesis was performed. Ethical approval was not required.

Results
Searches yielded 564 citations, of which 145 duplicates were removed. The title and abstract screening resulted in 16 full-text review studies. Of these, 8 studies were excluded. Therefore, this study included 8 RCTs, published between 2007 and 2019, conducted in different countries. The sample sizes were small for most RCTs (ranged from 225 to 1906). The range of CVD targeted was diverse: 3 included patients with dyslipidaemia, 2 with heart failure, 3 with hypertension. The most frequent pharmacist-led interventions (7 out of 8 RCTs) were multifaceted context and included medication reviews and adherence counselling; the intervention duration ranged from 2 to 12 months. The interventions were conducted in a primary care setting: 6 in pharmacies, one in a clinic, and one within a home visit. A total of five RCTs reported medication adherence as the primary outcome, and three reported clinical outcomes. RCTs used different measurements to assess adherence, 3 used self-reported and 5 used pharmacy refill records. Seven of the RCTs reported that interventions enhanced medication adherence, with 3 showed statistically significant improvements at 6 months and 12 months of the intervention. Five RCTs assessed the effect of the interventions on the clinical outcomes and reported a trend toward improvement in blood pressure and low-density lipoprotein cholesterol level in the intervention arm. Regarding the quality of evidence, most RCTs were classified as having poor quality because of the high risk of bias or insufficient reporting of information.

Conclusion
Pharmacist-led interventions tend to improve medication adherence and clinical outcomes, but interventions varied in terms of content and delivery. The precise design of the interventions with essential characteristics tailored to patients’ needs could increase the effectiveness of these interventions. Further large RCTs are required. Limitations of this review include the exclusion of non-English language studies. Further, the clinical and methodological heterogeneity of included studies made clear a quantitative comparison difficult, thus, the findings are based on narrative analysis.

References
(1) Naderi SH, Bestwick JP, Wald DS. Adherence to drugs that prevent cardiovascular disease: meta-analysis on 376,162 patients. Am J Med. 2012;125(9):882-7.e1.
(2) Yepes-Nuñez JJ, Urrútia G, Romero-García M, Alonso-Fernández S. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Rev Esp Cardiol (Engl Ed). 2021;74(9):790-9.