the most common drug-related problem that clinical pharmacists resolved was incorrect dosing (n=21). this was followed by drug-drug interactions (n=17), unclear drug information (n=14), improper dose form (n=12), inappropriate drug choice (n=10), adverse drug reactions (n=8), and non-compliance (n=7). the most common drp for which clinical pharmacists intervened was incorrect dosing (n=21). this was followed by drug-drug interactions (n=17), unclear drug information (n=14), and adverse drug reactions (n=8). drps leading to ineffective drug therapy, such as non-compliance or therapeutic duplication, were only reported in a few studies (n=3). most studies did not report the number of interventions that were rejected by physicians (n=14). the most common reasons for rejection were that the pharmacist was not authorised to perform the intervention, or that the intervention would require advanced clinical knowledge or skills. acceptance rates varied from 0% to 100%. if a drp was rejected by the physician, the actual reason for rejection was usually not reported. however, in one study, the reasons for rejection were reported in a structured fashion [ 31 ]. physicians reported that the clinical significance of a drp was not always obvious, and that they were not sufficiently trained or authorised to judge the clinical significance of a drp. furthermore, physicians mentioned issues such as cost, workload, and time constraints as reasons for rejecting drps, and wanted to be informed about their clinical significance before accepting interventions.
the most common drp categories in the included studies were the following: dose-related, non-adherence, adverse reactions, laboratory abnormalities, missed dose, and drug-drug interactions. the most common interventions were modification of drug dosing, dose and frequency of administration, and dose titration. the most common outcomes assessed were physician acceptance rate, resolution of drps, drp disclosure to the physician, and patient satisfaction. in addition to patient satisfaction, adverse drug reactions, therapy adherence, and medication errors were also commonly assessed. most of the studies were conducted in the united states and the netherlands. only one study was conducted in europe (belgium) [ 12 ]. the most commonly studied patient populations were patients on hd and pd. two studies examined the impact of clinical pharmacy services on all adult patients receiving haemodialysis and/or peritoneal dialysis, whereas the others focused on hd or pd. however, none of the studies focused on transplant recipients. a summary of the findings is shown in table 2.
the impact of a clinical pharmacist on adr detection and management is usually described in terms of aes and clinical outcomes. in some studies, adrs or aes were the primary outcomes of interest. in other studies, they were analysed as secondary outcomes. table 4 shows the primary and secondary outcomes of the studies, respectively. a significant decrease in the incidence of adrs was often identified in studies analysing adrs as a primary outcome. for example, a significant reduction in hospitalisations due to adrs was observed in a study on elderly patients [ 14 ]. in studies on other diseases, a significantly lower rate of hospitalisation due to cardiovascular events was identified [ 16, 29 ]. in a study on hd patients with secondary hyperparathyroidism, the rate of re-hospitalisation due to hypercalcaemia was significantly lower [ 30 ]. in a study on ckd patients, a significantly lower rate of all-cause hospitalisation was identified [ 18 ]. the impact of clinical pharmacist activities on clinical outcomes was analysed as a secondary outcome in a few studies. for example, a study on ckd patients reported that the mean length of hospital stay was significantly reduced [ 18 ]. two studies on hd patients reported a significantly higher rate of successful maintenance of dialysis after hospitalisation [ 24, 26 ].
less commonly, clinical pharmacist activities are reported in terms of changes in healthcare costs. an economic analysis was reported in two studies on ckd patients [ 16, 18 ]. although the overall total healthcare costs for ckd patients in the intervention group were significantly lower than the control group, the difference in total healthcare costs between the two groups was not significant. a significantly lower rate of hospitalisations was reported in a study on hd patients [ 24 ]. in this study, the amount of laboratory tests ordered by the clinical pharmacist was analysed as an economic outcome. in both groups, laboratory tests were ordered. however, the rate of laboratory tests ordered by the clinical pharmacist was significantly higher in the intervention group as compared to the control group.