The Value of Pharmacists in Health Care

Abstract

The American health care system is concerned about the rise of chronic diseases and related resource challenges. Management of chronic disease traditionally has been provided by physicians and nurses. The growth of the care management industry, in which nurses provide remote telephonic monitoring and coaching, testifies to the increasing need for care management and to the value of nonphysician clinicians. However, this model is challenged by a number of factors, including low enrollment and the growing shortage of nurses. The challenges to the traditional model are causing policy makers and payers to consider innovative models. One such model includes the pharmacist as an essential provider of care. Not only is the number of pharmacists growing, but they are playing an ever broader role in a variety of settings. This article broadly surveys the current state of pharmacist provision of care management services and highlights the increasingly proactive role played by Walgreen Co. toward this trend, using recently conducted research. Pharmacists are making a noticeable impact on and contribution to the care of chronic diseases by improving adherence to medications, a key factor in the improvement of outcomes. Literature also suggests that pharmacies are increasingly encouraging, expanding, and highlighting the role and contributions of their professional pharmacists. Although the role of the pharmacist in chronic care management is still developing, it is likely to grow in the future, given the needs of the health care system and patients. (Population Health Management 2012;15:157–162)

Introduction

T he US health care system is confronted with many issues, including escalating health care costs,¹ a rise in chronic disease prevalence,¹ and resource challenges (eg, physician shortages).² Therefore, the need for a team approach to patient care is becoming increasingly important.

To ensure that patients receive the quality care necessary for sustained health and well-being, it is essential for primary care providers and nonphysician clinicians to work together to provide optimal care. Nonphysician clinicians are able to assist primary care providers with ensuring that their patients receive all necessary and recommended care. This collaborative effort allows nonphysician clinicians to supplement the care provided by primary care physicians.

The unique characteristics of the pharmacist imply that the profession may fill an important role in chronic care management. Although there were 306,100 primary care physicians in the United States in 2005,³ there were 226,000 pharmacists, located in most communities throughout the country, in 2004.⁴ Pharmacies are generally open 7 days a week, and may be available 24 hours a day in some areas. Pharmacists may be accessed without an appointment, and patients interact with their pharmacist more often than their primary care provider.⁵

Today's practicing pharmacist provides a much broader range of services than was offered 10 years ago. The profession has effectively embraced the concept of pharmaceutical care and now extends beyond simple provision of medication therapy. A pharmacist's expertise with prescription drugs enables him or her to perform successful medication therapy management (MTM), engaging in efforts to improve the quality of the drug use process and to identify ways to reduce medication errors and suboptimal adherence, including patient counseling on the proper use of medication. Pharmacists are playing an increasingly more significant role in the provision of health care as well. Their interaction with chronic patients presents opportunities to provide essential counseling and education to patients, and to perform screenings and assessments.

Pharmacists have a key advantage over other care management service providers in that they interact frequently with chronic disease populations. In the traditional nurse call center model, data are analyzed to identify members with chronic illnesses, who then must be contacted and enrolled. The traditional outreach and engagement process is time-consuming, expensive, and has mixed results in terms of patient engagement. This model may be compared with a pharmacy-based model in which the patients are known to the pharmacy (because they refill medications there) and have frequent interactions with pharmacy staff. Many pharmacies are equipped with systems that can identify a gap in a medication fill, triggering reminders and other outreach.⁶

Today pharmacists are partnering with primary care physicians in a variety of ways. Pharmacists collaborate on medication optimization, polypharmacy, and medication safety. They also have formed partnerships on preventive interventions, such as lipid control, osteoporosis management, vaccination, and smoking cessation, making the pharmacist a valuable member of the health care team.

A number of well-known (and some lesser known) pharmacy-based pilot studies have been implemented. These include the Asheville and Diabetes Ten City Challenge studies. There is a growing body of literature demonstrating the effectiveness of pharmacist-led interventions in many different fields in health care. This article surveys some of the important research and publications that address the impact of the pharmacist on various aspects of health and related outcomes.

Methods

In addition to articles on the Asheville Project, Diabetes Ten City Challenge, and PharmacistCARE, research based on Walgreens experience related to the value of pharmacists in health care is presented here. A supplementary literature search also was carried out to identify more “pharmacist impact” articles. For our search, we used the key words “pharmacists” or “pharmacies” and “outcomes,” “clinical,” or “financial.” Searches were performed mainly in PubMed and at the Web site of the journal Annals of Pharmacotherapy. The searches resulted in the identification of 17 additional articles; 13 of these (6 of which were reviews) were judged by the reviewer to be the most suitable, based on the title and the abstract of the article.

Results

In this section we discuss the results observed in a number of pharmacist intervention programs. Results are grouped by the specific type of intervention the program focused on (MTM, chronic care management, and quality of life).

Medication management

Studies show that pharmacists are able to successfully perform medication management for their patients. Unlike physicians, who often lack complete drug profiles, pharmacists are presented with unique opportunities to review patients' medication profiles for drug interactions, duplications, and deficient therapies, and to work with physicians to correct therapies, the result of which may be to prevent adverse effects and decrease health care costs.

Several studies examine the pharmacist's ability to identify potentially harmful prescription errors and have such regimens modified.^7

–10 The impact of the medication errors identified in these studies ranged from negative side effects to hospital admission. Pharmacist-led MTM also can beneficially impact health costs. A study by Barnett et al¹¹ showed the average estimated health care cost avoidance for 2000–2006 to be $93.78 per MTM claim. Furthermore, Isetts et al¹⁰ found that MTM services were associated with a decrease in total health care costs of $3768 per person.

Pharmacists also have the ability to identify patients with inadequate medication adherence and to intervene with education and counseling sessions that highlight the importance of taking medication as directed, as well as to discuss any side effects the patient may be experiencing, resulting in improved medication adherence.

Lee and colleagues¹² studied the ability of a pharmacist-led intervention to impact adherence in a group of chronic disease patients aged 65 years and older who take 4 or more maintenance medications. When the patients in this study received pharmacist care, they were able to achieve a significant improvement in medication adherence. The patients went from a baseline adherence rate of 61.2% to 96.9% (an increase of 35.7 points, P<0.001) at study end (8 months). It is important to note that the chronic disease patients in this study were able to achieve an average adherence rate of greater than 80% with pharmacist intervention. An adherence level of 80% is considered an important target of successful chronic care management.¹³ Furthermore, the proportion of patients with an adherence rate of ≥80% for all their maintenance medications increased from 5.0% at baseline to 98.7% (P<0.001) at study end. Rubio et al¹⁴ performed a meta-analysis of 6 randomized controlled trials that specifically examined pharmacist impact on adherence to antidepressants for patients suffering from depression. The resulting collective odds ratio was 1.64 (95% confidence interval 1.24 to 2.17, P<0.001), indicating that pharmacist intervention results in improved antidepressant medication adherence for patients with depression.

The impact of worksite health and pharmacy services on medication adherence also has been evaluated. One of the studies compared chronic disease patients who use worksite health and pharmacy services to those who use community services.¹⁵ Overall, patients in the worksite group had a medication adherence rate that was 9.72% higher (P<0.0001) than the community group. The other study compared medication adherence for patients who use a worksite pharmacy and those who use mail-order pharmacy services.¹⁶ This retrospective analysis found that chronic disease patients who filled their prescriptions at a workplace pharmacy had a higher rate of adherence compared to patients who filled prescriptions through mail order (81.14% vs. 78.26%, P<0.0001). Furthermore, utilizers of worksite pharmacies had significantly fewer gaps in therapy of 30 days or more compared to patients who used mail order (45.02% vs. 57.84%, P<0.0001). The authors speculated that the observed increase in adherence may be related, in part, to the beneficial effects of pharmacist–patient interaction, including counseling and educating patients on the importance of adhering to a drug regimen.

Chronic care management

Numerous studies highlighting pharmacist impact on the management of chronic disease have been published. These studies illustrate the ability of pharmacists to effectively coordinate care with physicians and other clinicians to treat patients with chronic conditions such as diabetes, hypertension, and asthma. One of the most notable studies concerns Asheville, NC.

The Asheville Project, as it is known, examined the impact of providing community pharmacy-based diabetes care.¹⁷ Participating pharmacists were trained and certified on diabetes care. Patients taking part in the program received a zero co-pay incentive for diabetes medications and supplies. The project consisted of patients meeting monthly with a pharmacist for counseling and monitoring of disease status. During these sessions, pharmacists would check the patient's blood pressure, weight, and feet, allowing patients to receive such care in a convenient accessible manner. Patients in this study realized a significant decrease in average glycosylated hemoglobin (A1c) values (7.0% vs. 7.5%, P<0.01) in the short term. They also were able to achieve improvement in A1c, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) values at every follow-up as the study progressed.¹⁸ Furthermore, per person per year total direct medical costs decreased each year of the study. Although several factors contributed to the success of the program, the ability to receive diabetes care support from a local pharmacist was an important aspect.

The Diabetes Ten City Challenge (2005) further showcased the value of pharmacist-led interventions.¹⁹ Unlike the Asheville Project, which was limited to 1 city, the Diabetes Ten City Challenge was implemented across 10 different cities around the United States. The program was modeled after the Asheville Project in that it focused on patients with diabetes. In this employer-sponsored program supported by more than 30 employers, pharmacists worked collaboratively with employers, employees, physicians, and diabetes educators in focusing on wellness, patient self-management, and workplace cost savings. As with the Asheville Project, specially trained community pharmacists coached patients on how to manage their diabetes, including setting goals, using medications properly, and tracking their condition consistently. Clinical outcomes, such as A1c, LDL levels, and blood pressure, were used to gauge success. After 1 year, patients reduced their average A1c by 5.2% (from 7.6% to 7.2%), LDL by 3.1% (from 96.3 to 93.3 mg/dL), systolic blood pressure by 2% (from 131.3 to 128.7 mmHg), and diastolic blood pressure by 2.5% (from 79.3 to 77.3 mmHg). The percentage of patients who received a seasonal influenza vaccination increased by 18 points (from 43% to 61%), and the percentage who received a foot exam increased by 30% (from 38% to 68%).

In 2003, the University of Kentucky established another pharmacist-oriented program called PharmacistCARE.²⁰ The program had 2 components: DiabetesCARE and CardioCARE. In this program, more than 300 patients were provided pharmacist-led care. Pharmacist–patient interaction took place in a pharmacist-run clinic, which was located inside an ambulatory care facility. For DiabetesCARE, patients met with a pharmacist for 1 hour at the beginning of the study. The patients then attended several sessions on self-management education. After successfully completing the education portion, patients met with the pharmacist every few months to have foot and weight assessments, blood pressure checked, and to have A1c and lipid values tested. After 1 year, the percentage of diabetes patients with an average A1c of >9% dropped by 16 points (from 26% to 10%). The percentage of patients who received a seasonal influenza vaccination increased by 16 points (from 55% to 71%), and the percentage who received a pneumonia vaccination increased by 18% (from 28% to 46%). Furthermore, the percentage of patients with an LDL value ≤130 mg/dL improved by 29% (from 52% to 81%).

The 3 programs discussed in detail above were prospectively designed for diabetes management. Several retrospective studies also show that pharmacists play an important role in diabetes management. Johnson et al²¹ conducted a study using chart review of 222 patients who received pharmacist care and 262 who received “usual care.” Patients had to be under- or uninsured and have uncontrolled (A1c of >9%) type 2 diabetes to be included in the study. The authors evaluated the change in A1c levels and the ability to achieve treatment goals between the 2 groups. The A1c values of patients who received care from a pharmacist were 1.38% lower than those of the control patients. Kiel and McCord²² also conducted a retrospective study that assessed the impact of pharmacists on clinical outcomes for patients with diabetes. Comparing pre- and post-enrollment lab values in the pharmacist program, the authors found the percentage of patients with an A1c value of <7% increased 31 points (19% to 50%, P<0.001) and the average A1c value decreased 1.6% (P<0.001). Furthermore, average LDL values decreased from 116 mg/dL to 100 mg/dL and average HDL increased from 46 mg/dL to 48 mg/dl (both results were nonsignificant).

The impact of a worksite pharmacy-based diabetes patient education program also has been examined.²³ The program, known as “Dimensions,” was implemented in 2008 and was employer funded. As with the Asheville Project and the Diabetes Ten City Challenge, all participating pharmacists completed a diabetes certification course. The Dimensions program included 185 patients who met monthly with the pharmacist at program start and then every other month throughout the study. Pharmacist involvement included conducting a review of patients' medication therapies, assessing patients' adherence to their regimens, and educating patients. Program enrollees achieved a significant reduction in A1c values (7.72% at baseline vs. 7.05% at study end, P<.0001). Furthermore, patients experienced a significant improvement in HDL (42.75 mg/dL vs. 44.38 mg/dL, P=.0451).

Machado et al²⁴ conducted a meta-analysis of 36 studies that examined pharmacist-led interventions for diabetes care in a variety of settings, including community pharmacies, ambulatory clinics, and hospitals. The authors sought to determine which clinical outcomes were capable of being significantly improved by pharmacist intervention. The authors concluded that A1c is sensitive to pharmacist intervention, finding a clinically and statistically significant reduction between baseline and study end for the intervened patients (1.00±0.28%; P<0.001), and none for the usual care group (0.28±0.29%; P=0.335).

Although the role of pharmacists in diabetes management has been more widely studied, there is some literature that highlights the important impact pharmacists have on the management of hypertension. Following the success of the Asheville Project with diabetes management, an extension was created that focused on hypertension and hyperlipidemia. The study resulted in patients achieving a statistically significant reduction in systolic and diastolic blood pressure²⁵; average systolic blood pressure decreased from 137.3 mmHg at baseline to 126.3 mmHg at study end (P<0.0001), and diastolic blood pressure was reduced from 82.6 mmHg to 77.8 mmHg (P<0.0001).

Robinson et al²⁶ conducted a 12-month prospective study that compared patients with inadequately controlled hypertension (ie, blood pressure of > 140/90 mmHg) who received pharmacist care to those who received usual care. The authors demonstrated that community pharmacist education and counseling was associated with a significant reduction in systolic blood pressure for hypertensive patients; patients who received pharmacist care were able to reduce their systolic blood pressure by 9.9 mmHg, whereas patients who received usual care had an average reduction of 2.8 mmHg (P<0.05). The authors also found a higher rate of adherence to antihypertensive medication in the pharmacist intervened group during the first 6 months of the study (91% vs. 78%, P=0.02). However, this effect did not persist through the remaining 6 months of the study.

Sookaneknun et al²⁷ also tested the effect of pharmacist care on patients with hypertension in a randomized controlled pre-post study performed in Thailand. Compared to patients who received usual care, patients who received pharmacist care experienced a decrease in both systolic blood pressure (P=0.037) and diastolic blood pressure (P=0.027). Furthermore, the number of patients with “good” medication adherence (≥80%) rose from 58 at baseline to 70 at study end for the intervention group, compared to 61 at baseline and 60 at study end for the usual care group (P=0.014).

Machado et al²⁸ performed another meta-analysis, this time examining pharmacist-led interventions for hypertension care. Study results showed that systolic blood pressure is sensitive to pharmacist intervention; clinically and statistically significant differences in systolic blood pressure were observed between baseline and study end for the patients who received the pharmacist intervention (difference of 10.7 mmHg, P=0.002), and none were observed for the usual care group (difference of 3.6 mmHg, P=0.06). Comparison of diastolic blood pressure did not prove to be sensitive, but significant reduction was observed in the intervention group.

Pharmacists are making a meaningful contribution to the management of hyperlipidemia, another chronic condition. As mentioned, an extension of the Asheville Project was created to examine the impact of pharmacist care on outcomes for patients with hypertension and/or hyperlipidemia.²⁵ Patients in the study achieved a statistically significant reduction in LDL (127.2 mg/dL at baseline to 108.3 mg/dL at study end, P<0.0001), total cholesterol (from 211.4 mg/dL to 184.3 mg/dL, P<0.0001), and triglycerides (from 192.8 mg/dL to 154.4 mg/dL, P<0.0001). No improvement in HDL was observed.

Another random effects meta-analysis was conducted by Machado et al.²⁹ The focus of this study was to assess whether pharmacist care could improve health outcomes for patients with hyperlipidemia. Study results indicated that total cholesterol is sensitive to pharmacist intervention; average values in the intervention group were significantly reduced by 34.3 mg/dL (P<0.001) compared to 22.0 mg/dL (P=0.034) for the control group. The authors could not fully conclude that LDL, HDL, and triglycerides are sensitive to pharmacist-led intervention.

Pharmacists also have played a role in asthma management. The Asheville Project looked at the impact of pharmacist care on outcomes for patients with asthma.³⁰ Patients in the study were able to achieve significant improvement in asthma-related outcomes. At baseline, 63% of the patients reported having an asthma action plan completed. This number rose to 99% after 1 year. Furthermore, the percentage of patients who visited an emergency room (9.9% vs. 1.3%) and hospital decreased (4.0% vs. 1.9%). Patients also experienced significant improvement in the severity of their asthma. After 5 years, savings from direct medical costs averaged $725 per patient per year.

Benavide et al³¹ performed a systematic review of 25 studies that examined the impact of pharmacist intervention on asthma-related outcomes, 15 of which took place in a community pharmacy. All but 1 of the studies assessing respiratory function in the community pharmacy setting showed improvement. Pharmacist intervention was associated with decreased hospital and emergency room visits in 3 of 4 studies. Results for asthma severity and quality of life improvement were mixed.

Health-Related Quality of Life (HRQL)

Studying HRQL is difficult and controversial, despite its importance as an outcome. Limited evidence is available to evaluate the role of pharmacists in adding value to this domain. A systematic review of 36 articles from 1999 through 2004 conducted by Pickard and Hung³² studied the relationship between HRQL and clinical pharmacy services. The authors found improvement in HRQL for patients with hypertension, asthma, and chronic heart failure.

Summary

As demonstrated by this review of the literature, pharmacists are playing a significant role in the care of patients. The studies summarized in this article show that pharmacists are able to make a noticeable impact on and contribution to the care of chronic patients with whom they interact on a regular basis.

As physician shortages and chronic condition prevalence are poised to increase, pharmacists can take a more proactive role in the care of their patients. Given their proven ability to effectively impact patient care, adding pharmacists to the medical team may benefit not only the patient but the health care system as well. Having pharmacists lead certain aspects of care can help to diminish the burden on physicians. It also may provide access to care for patients who live in medically underserved areas, as there typically is a community pharmacy located within 5 miles of most Americans.³³ Adding to the convenience, access to a pharmacist often is available 24 hours a day and without an appointment.

It is important to note that, although only certain aspects of pharmacist care were discussed in this paper, pharmacists have expanded their role to include a host of other services. More recently, community pharmacies have received significant press for their immunization services. Community pharmacies offer patients an extensive network of certified immunizers. Walgreens alone has over 26,000 pharmacists available to administer vaccines.⁶ Furthermore, this summary article has several limitations. This was not a systematic review; a very limited number of studies were selected for inclusion in this paper. Furthermore, the quality of those studies that were selected was not assessed. Additionally, this article included only simple summaries of studies, with no critical review being performed. Finally, the research presented in this paper may not be representative of all studies published on the subject.

The pharmacist can play a significant role in patient care, partnering with physicians and other clinicians to ensure adequate access and provision of care for patients. This team of providers can work together to lower medical costs, decrease hospitalizations, and ultimately improve the health and wellness of their patients.

Footnotes

Author Disclosure Statement

Drs. Patwardhan and Pegus, and Mr Duncan and Ms Murphy are employees of Walgreen Co., the funder of this study. Self-funded by Walgreen Co.

References

DeVol

, Bedroussian

. An unhealthy America: The economic burden of chronic disease. Charting a new course to save lives and increase productivity and economic growth. http://www.milkeninstitute.org/publications/publications.taf?function=detail&ID=38801018&cat=resrep. 2010 February 15.

Dill

, Salsberg

. The complexities of physician supply and demand: Projections through 2025. http://www.tht.org/education/resources/AAMC.pdf. 2010 June 10.

US Department of Health and Human Services. Health Resources and Services Administration; Bureau of Health Professions. The physician workforce: Projections and research into current issues affecting supply and demand. ftp://ftp.hrsa.gov/bhpr/workforce/physicianworkforce.pdf. 2011 March 15.

U.S. Department of Health and Human Services. Health Resources and Services Administration. Bureau of Health Professions. The adequacy of pharmacist supply: 2004 to 2030. http://bhpr.hrsa.gov/healthworkforce/pharmacy/pharmacistsupply.pdf. 2011 March 15.

Tsuyuki

, Johnson

, Teo

et al.

A randomized trial of the effect of community pharmacist intervention on cholesterol risk management: The Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP)

Arch Intern Med, 2002; 162:1149–1155.

Sax

. Chain drugstores: Providing effective patient care and professional development. http://www.pharmacytimes.com/publications/career/2011/PharmacyCareers_Spring2011/ChainDrugstores-2011. 2011 May 3.

Buurma

, De Smet

, Leufkens

, Egberts

. Evaluation of the clinical value of pharmacists' modifications of prescription errors. Br J Clin Pharmacol, 2004; 58:503–511.

Rupp

. Value of community pharmacists' interventions to correct prescribing errors. Ann Pharmacother, 1992; 26:1580–1584.

Hawksworth

, Corlett

, Wright

, Chrystyn

. Clinical pharmacy interventions by community pharmacists during the dispensing process. Br J Clin Pharmacol, 1999; 47:695–700.

10.

Isetts

, Schondelmeyer

, Artz

et al. Clinical and economic outcomes of medication therapy management services: The Minnesota experience. J Am Pharm Assoc (2003), 2008; 48:203–211.

11.

Barnett

, Frank

, Wehring

et al. Analysis of pharmacist-provided medication therapy management (MTM) services in community pharmacies over 7 years. J Manag Care Pharm, 2009; 15:18–31.

12.

Lee

, Grace

, Taylor

. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: A randomized controlled trial. JAMA, 2006; 296:2563–2571.

13.

Sokol

, McGuigan

, Verbrugge

, Epstein

. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care, 2005; 43:521–530.

14.

Rubio-Valera

, Serrano-Blanco

, Magdalena-Belío

et al. Effectiveness of pharmacist care in the improvement of adherence to antidepressants: A systematic review and meta-analysis. Ann Pharmacother, 2011; 45:39–48.

15.

Sherman

, Frazee

, Fabius

, Broome

, Manfred

, Davis

. Impact of workplace health services on adherence to chronic medications. Am J Manag Care, 2009; 15:e53–e59.

16.

Patwardhan

, Davis

, Murphy

, Khandelwal

, Sherman

, Manfred

. The impact of 90-day prescriptions on adherence at workplace pharmacies compared to traditional mail order. Popul Health Manag, 2011; 14:285–291.

17.

Cranor

, Christensen

. The Asheville Project: Short-term outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash), 2003; 43:149–159.

18.

Cranor

, Bunting

, Christensen

. The Asheville Project: Long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash), 2003; 43:173–184.

19.

Fera

, Bluml

, Eliis

, Schaller

, Garrett

. The Diabetes Ten City Challenge: Interim clinical and humanistic outcomes of a multisite community pharmacy diabetes care program. J Am Pharm Assoc (2003), 2008; 48:181–190.

20.

Divine

, Nicholas

, Johnson

, Perrier

, Steinke

, Blumenschein

. PharmacistCARE: Description of a pharmacist care service and lessons learned along the way. J Am Pharm Assoc (2003), 2008; 48:793–802.

21.

Johnson

, Chen

, Cheng

I-N

et al. The impact of clinical pharmacy services integrated into medical homes on diabetes-related clinical outcomes. Ann Pharmacother, 2010; 44:1877–1886.

22.

Kiel

, McCord

. Pharmacist impact on clinical outcomes in a diabetes disease management program via collaborative practice. Ann Pharmacother, 2005; 39:1828–1832.

23.

Frazee

, Raulerson

, Schwab

et al. Improving health outcomes and reducing cost in chronic disease management: Impact of a pharmacist-led diabetes education program at a workplace pharmacy. Health Productivity Manage, 2010; 8:32–36.

24.

Machado

, Bajcar

, Guzzo

, Einarson

. Sensitivity of patient outcomes to pharmacist interventions. Part I: Systematic review and meta-analysis in diabetes management. Ann Pharmacother, 2007; 41:1569–1582.

25.

Bunting

, Smith

, Sutherland

. The Asheville project: Clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc (2003), 2008; 48:23–31.

26.

Robinson

, Segal

, Lopez

, Doty

. Impact of a pharmaceutical care intervention on blood pressure control in a chain pharmacy practice. Ann Pharmacother, 2010; 44:88–96.

27.

Sookaneknun

, Richards

, Sanguansermsri

, Teerasut

. Pharmacist involvement in primary care improves hypertensive patient clinical outcomes. Ann Pharmacother, 2004; 38:2023–2028.

28.

Machado

, Bajcar

, Guzzo

, Einarson

. Sensitivity of patient outcomes to pharmacist interventions. Part II: Systematic review and meta-analysis in hypertension management. Ann Pharmacother, 2007; 41:1770–1781.

29.

Machado

, Nassor

, Bajcar

, Guzzo

, Einarson

. Sensitivity of patient outcomes to pharmacist interventions. Part III: Systematic review and meta-analysis in hyperlipidemia management. Ann Pharmacother, 2008; 42:1195–1207.

30.

Bunting

, Cranor

. The Asheville project: Long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma. J Am Pharm Assoc (2003), 2006; 46:133–147.

31.

Benavides

, Rodriguez

, Maniscalco-Feichtl

. Pharmacist involvement in improving asthma outcomes in various healthcare settings: 1997 to present. Ann Pharmacother, 2009; 43:85–97.

32.

Pickard

, Hung

. An update on evidence of clinical pharmacy services' impact on health-related quality of life. Ann Pharmacother., 2006; 40:1623–1634.

33.

National Association of Chain Drug Stores. Pharmacies: Improving health, reducing costs. http://www.nacds.org/user-assets/pdfs/2011/PrinciplesOfHealthcare.pdf. 2011 May 3.