Effect of pharmaceutical care interventions on glycemic control in patients with diabetes: a systematic review and meta-analysis

Figures & data

Figure 1 PRISMA flow diagram of selected publications in systematic review and meta-analysis.

Abbreviation: RCT, randomized controlled trial.

Table 1 Characteristics of randomized controlled studies included in the final analysis

Study ID	Country	Patients	PC/UC (n)	Setting	Care initiative	Intervention type	Duration (months)	Clinical outcomes
Jaber 1996^Citation42	USA	T2DM	17/22	University- affiliated internal medicine outpatient clinic	Pharmacist	Dosage evaluation, patient education, training on hyper and hypoglycemia, medication counseling, dietary regulation and exercise plan, and self-monitoring of blood glucose	4	HbA1c, FBG
Clifford 2002^Citation43	Australia	T1DM, T2DM	48/25	Hospital	MTC	Education and a brochure on risk factors, point-of-care cholesterol measurement, referral to their physician, and drug monitoring	6	HbA1c
Raji 2002^Citation44	USA	T1DM, T2DM	50/56	Veterans health care system	MTC	3.5 day-structured curriculum, disease education, group discussion, lifestyle management by direct counseling or telephone intervention, and newsletter provided	12	HbA1c
Choe 2005^Citation45	USA	T2DM	29/36	University- affiliated primary care clinic	Pharmacist	Medication review and reconciliation, telephone intervention, lifestyle management, and self-monitoring blood glucose	12	HbA1c
Clifford 2005^Citation46	Australia	T2DM	92/88	Fremantle Diabetes Study	Pharmacist	Bimonthly newsletter, educational pamphlets, pharmacotherapeutic intervention, diet, exercise, and compliance with home blood glucose monitoring	12	HbA1c
Rothman 2005^Citation47	USA	T2DM	112/105	University of North Carolina General Internal Medicine Practice	Pharmacist	Intensive education and counseling, medication management, and applying evidence-based treatment algorithms	12	HbA1c
Suppapitiporn 2005^Citation48	Thailand	T2DM	180/180	Hospital	Pharmacist	Patient counseling, drug education, special medication container, and booklet provided	6	HbA1c, FBG
Fornos 2006^Citation49	Spain	T2DM	56/56	14 community pharmacies	Pharmacist	Pharmacotherapy follow-up program, adherence education, and medication reconciliation	14	HbA1c, FBG
Scott 2006^Citation50	USA	T2DM	76/73	Community Health Center	MTC	Group session appointment, medication review, aspirin therapy and influenza vaccination education, lifestyle management, and telephone follow-up	9	HbA1c, FBG
Krass 2007^Citation51	Australia	T2DM	149/140	Quality care pharmacy program affiliated to 56 pharmacies	Pharmacist	Review of self-monitoring of blood glucose, disease, medication, and lifestyle education	6	HbA1c
Phumipamorn 2008^Citation52	Thailand	T1DM, T2DM	67/68	30-bed community hospital	Pharmacist	Medication adherence, lifestyle management, and leaflet provided	10	HbA1c
Al Mazroui 2008^Citation53	UAE	T2DM	117/117	Military hospital	MTC	Drug education, lifestyle management, leaflet, and medication reconciliation	12	FBG
Edelman 2010^Citation16	USA	T1DM, T2DM	133/106	Two VA medical centers	MTC	Group medical clinic participation, disease education, disease, and medication review	12.8	HbA1c
Farsaei 2011^Citation26	Iran	T2DM	87/87	One outpatient clinic	MTC	Education and telephone counseling	3	HbA1c, FBG
Jameson 2010^Citation18	USA	T1DM, T2DM	52/51	AHPN	Pharmacist	Individualized education regarding diabetes self-management (diet, exercise, blood glucose level testing, medications, and insulin), early switching to insulin therapy after failure of two oral medications	12	HbA1c
Kirwin 2010^Citation54	USA	T1DM, T2DM	150/151	Four medical clinics	MTC	Medication review and treatment recommendation letter to physician	10	HbA1c, LDL
Taveira 2010^Citation55	USA	T2DM	58/51	VA medical center	MTC	Patients’ didactic education and behavioral and pharmacological intervention by pharmacist	4	HbA1c
Cohen 2011^Citation56	USA	T2DM	50/49	VA medical center	MTC	Four once weekly 2-hour sessions of education and behavioral and pharmacologic intervention review	6	HbA1c
Mehuys 2011^Citation57	Belgium	T2DM	153/135	66 community pharmacies	MTC	Disease education, lifestyle management, medication adherence, and regular checkup reminding	6	HbA1c, FBG
Obreli-Neto 2011^Citation27	Brazil	T1DM, T2DM	97/97	Public primary health care unit	MTC	Group discussion, drug education, lifestyle management, patients’ counseling, and medication reconciliation	36	HbA1c, FBG
Simpson 2011^Citation58	Canada	T2DM	131/129	Five primary care clinics	Pharmacist	Medication review and implementation of guideline concordant recommendations	12	HbA1c
Siriam 2011^Citation59	India	T2DM	60/60	Multi-specialty tertiary care teaching hospital	Pharmacist	Medication counseling, dietary regulation, exercise, and lifestyle modifications	3	HbA1c, FBG
Ali 2012^Citation60	UK	T2DM	23/23	Two community pharmacies	Pharmacist	Lifestyle management, medication review, disease education, and medication reconciliation	12	HbA1c
Chan 2012^Citation61	Hong Kong	T2DM	51/54	250-bed public convalescent hospital	Pharmacist	Disease education, medication adherence, and provided color stickers to identify drugs	9	HbA1c, FBG
Jacobs 2012^Citation62	USA	T2DM	72/92	Ambulatory general internal medicine setting	Pharmacist	Medication review, physical assessment, patients’ counseling, disease education, and lifestyle management	12	HbA1c
Jarab 2012^Citation35	Jordan	T2DM	85/86	762-bed RMS hospital	Pharmacist	Structured patient education and discussion about type 2 diabetes, risks and types of complications from diabetes, prescribed drug therapy, and proper dosage	6	HbA1c
Kraemer 2011^Citation5	USA	T1DM, T2DM	36/31	Several employer-based health care plans	Pharmacist	Disease education, patients’ counseling, and referral to physician	12	HbA1c, FBG
Mahwi 2013^Citation28	Iraq	T2DM	62/61	Diabetic center	Pharmacist	Drug therapy problems and compliance by pill count and Morisky–Green test for drug adherence	4	HbA1c, FBG
Mourao 2013^Citation34	Brazil	T2DM	50/50	Six primary health care units integrated into the Brazilian public health system	Pharmacist	Patient education and/or pharmacotherapy changes	6	HbA1c
Samtia 2013^Citation29	Pakistan	T2DM	174/168	Diabetes clinics	Pharmacist	Disease education, drug education, and monitoring	5	HbA1c, FBG
O’Connor 2014^Citation63	USA	T1DM, T2DM	92/103	Kaiser Permanente Health Group	MTC	Protocol-structured telephone call and medication adherence reinforcement method	6	HbA1c
Chung 2014^Citation64	Thailand	T2DM	120/121	Major teaching hospital	Pharmacist	Medication review, solving drug-related problem, education on diabetes, hypertension, and hyperlipidemia	12	HbA1c, FBG
Cani 2015^Citation31	Brazil	T2DM	41/37	Teaching hospital	Pharmacist	Individualized pharmaceutical care plan	6	HbA1c
Jahangard- Rafsanjani 2015^Citation32	Iran	T2DM	51/50	Community pharmacy	Pharmacist	Blood glucose self-monitoring device, special logbook and education pamphlets, and medication reconciliation	5	HbA1c
Wishah 2015^Citation30	Jordan	T2DM	52/54	University hospital	MTC	Structured patients’ education and counseling for disease, medication, and lifestyle modification	6	HbA1c, FBG
Chen 2016^Citation65	Taiwan	T2DM	50/50	Hospital	Pharmacist	Assessment of adherence, pillbox, insulin injection technique, and medication regiment appropriateness (medication reconciliation)	6	HbA1c
Lim 2016^Citation33	Malaysia	T2DM	39/37	Hospital	Pharmacist	Booklet for disease and medication information, medication counseling, and education	32	HbA1c

Abbreviations: PC/UC, pharmacist care/usual care; T2DM, type 2 diabetes mellitus; FBG, fasting blood glucose; T1DM, type 1 diabetes mellitus; MTC, Multidisciplinary Team Care; VA, Veterans Affairs; AHPN, Advantage Health Physician Network; RMS, royal medical services; LDL, low density lipoprotein.

Figure 2 The overall comparison of PC and UC on the improvement of HbA1C level changes.

Abbreviations: PC, pharmacist care; UC, usual care; SDM, standard difference in mean values.

Figure 3 Meta-analysis of proportion of patients achieving target HbA1c levels between the PC and UC groups.

Abbreviations: PC, pharmacist care; UC, usual care.

Figure 4 Effect of PC and UC in the improvement of HbA1C levels stratified by income level (A) and intervention period (B).

Abbreviations: PC, pharmacist care; UC, usual care; SDM, standard difference in mean values.

Figure S1 Publication bias visualized by funnel plot.

Abbreviation: SDM, standard difference in mean values.

Table S1 The changes in HbA1C between PC group and UC group

Study ID	Intervention group		Control group		Sample size		P-value
	Pre	Post	Pre	Post	PC	UC
Jaber 1996^Citation12	11.5±2.9	9.2±2.1	12.2±3.5	12.1±3.7	17	22	0.003
Clifford 2002^Citation13	8.4±1.4	8.2±1.5	8.5±1.6	8.1±1.6	48	25	>0.05
Raji 2002^Citation14	9.9±1.3	8±1.4	9.8±1.2	8.6±1.8	50	56	0.03
Choe 2005^Citation15	10.1±1.8	8±1.4	10.2±1.7	9.3±2.1	29	36	0.03
Clifford 2005^Citation16	−0.5 (−0.7 to −0.3)		0 (−0.2 to 0.2)		92	88	0.002
Rothman 2005^Citation17	0.8 (0–1.7%)				112	105	0.05
Suppapitiporn 2005^Citation18	8.16±1.44	7.91±1.27	8.01±1.51	8.8±1.36	180	180	0.001
Fornos 2006^Citation19	8.4±1.8	7.9±1.7	7.8±1.7	8.5±1.9	56	56	0.001
Scott 2006^Citation20	8.8±1.72	7.08±1.72	8.7±0.7	8±0.7	64	67	0.012
Krass 2007^Citation21	8.9±1.4	7.9±1.2	8.3±1.3	8.0±1.2	125	107	<0.01
Phumipamorn 2008^Citation22	8.7±1.5	7.9±1.4	8.7±1.6	8.1±1.9	63	67	0.56
Al Mazroui 2009^Citation23	8.5 (8.3–8.7)	6.9 (6.7–7.1)	8.4 (8.2–8.6)	8.3 (8.1–8.5)	117	117	0.001
Edelman 2010^Citation1	9.2	8.3	9.2	8.6	133	106	0.159
	−0.33 (−0.80 to 0.13)
Farsaei 2010^Citation24	9.3±1.7	7.5±1.6	8.9±1.1	9.0±1.2	87	87	>0.05
Jameson 2010^Citation25	−1.5 (−0.03 to −2.68)		−0.40 (0.5 to −2.10)		52	51	0.06
Cohen 2011^Citation26	−0.41 (−0.74 to −0.07)		−0.20 (−0.61 to 0.21)		50	49	0.028
Mehuys 2011^Citation27	7.7±1.7	7.1±1.1	7.3±1.2	7.2±1	153	135	0.009
Obreli-Neto 2011^Citation3	−0.7 (−0.9 to 0.5)		0.0 (−0.1 to 0.1)		97	97	0.001
Simpson 2011^Citation28	−0.15 (−0.36 to 0.05)		0.03 (−0.22 to 0.28)		131	129	<0.05
Siriam 2011^Citation29	8.44±0.29	6.73±0.21	9.03±0.46	8.3±0.16	60	60	0.010
Ali 2012^Citation30	8.2±1.65	6.6±0.59	8.1±0.97	7.5±0.64	23	23	0.001
Chan 2012^Citation31	−1.57%+1.50%		−0.40%+1.19%		51	54	<0.00
Jacobs 2012^Citation32	9.5±1.1	7.7±1.3	9.2±1	8.4±1.6	72	92	0.003
Jarab 2012^Citation4	−0.8 (−1.6 to 0.1)		0.1 (−0.4 to 0.7)		77	79	0.019
Kraemer 2012^Citation5	7.28	6.78	7.38	7.22	36	31	0.0757
	−0.5 (change in mean values)		−0.16 (change in mean values)
Mahwi 2013^Citation6	11.53±1.83	9.2±2	9.97±2.75	9.5±2.1	62	61	0.001
Mourao 2013^Citation33	−0.6 (−1.1 to −0.02)		0.7 (0.2–1.3)		50	50	0.001
Samtia 2013^Citation7	8.51±1.62	7.5±1.26	8.54±1.55	8.08±1.49	178	170	0.001
O’Connor 2014^Citation34	−0.9±1.85		−1.08±1.78		92	103	0.001
Cani 2015^Citation8	9.78±1.55	9.21±1.41	9.61±1.38	9.53±1.68	34	36	0.001
Jahangard-Rafsanjani 2015^Citation9	7.6±1.6	6.6±1.5	7.5±1.9	7.0±1.7	51	50	0.09
Wishah 2015^Citation10	8.9±1.6	7.2±0.9	8.2±1.3	7.9±1.3	52	54	>0.05
Chen 2016^Citation35	9.22±1.7	8.39±1.2	8.94±1.5	9.37±1.5	50	50	0.002
Lim 2016^Citation11	10.11±0.26	9.21±0.27	9.71±0.34	9.63±0.29	39	37	0.001

Abbreviations: PC, pharmacist care; UC, usual care.

Table S2 Proportion of patients achieving HbA1c goal between PC group and UC group

Study ID	Goal	Intervention group		Control group
		Total (n)	Event (n)	Total (n)	Event (n)
Scott 2006^Citation20	A1C<7%	64	24	67	4
Kirwin 2010^Citation36	A1C<7%	150	65	151	57
Taveira 2010^Citation37	A1C<7%	58	23	51	11
Cohen 2011^Citation26	A1C<7%	50	20	49	10
Mehuys 2011^Citation27	A1C<7%	153	80	135	67
Obreli-Neto 2011^Citation3	A1C<7%	97	19	97	1
Chan 2012^Citation31	A1C<7%	51	3	54	0
Jacobs 2012^Citation38	A1C<7%	55	19	67	14

Abbreviations: PC, pharmacist care; UC, usual care.

Table S3 Quality check for included studies (randomized controlled studies) by EPOC risk of bias

Study ID	Sequence generation	Allocation concealment	Baseline outcome measurements	Baseline characteristics	Incomplete outcome data	Blinding of participants, personnel	Protection against contamination	Selective outcome reporting	Other sources of bias
Jaber 1996^Citation12	Unclear	Unclear	Low	Low	Low	Unclear	Unclear	Low	Unclear
Clifford 2002^Citation13	Low	Unclear	Low	Low	Low	Unclear	Unclear	Low	Unclear
Raji 2002^Citation14	Unclear	Unclear	Low	Low	Low	Unclear	Unclear	Low	Unclear
Choe 2005^Citation15	Low	Unclear	Low	Low	Low	High	Low	Low	Unclear
Clifford 2005^Citation16	Unclear	Unclear	Low	Low	Low	Low	Low	Low	Unclear
Rothman 2005^Citation17	Low	Low	Low	Low	Low	Unclear	Low	Low	Unclear
Suppapitiporn 2005^Citation18	Unclear	Unclear	Low	Low	Low	Unclear	Unclear	Low	Unclear
Fornos 2006^Citation19	Low	Unclear	Low	Low	Low	High	Low	Unclear	Unclear
Scott 2006^Citation20	Low	Unclear	Low	Low	Low	High	Low	Unclear	Unclear
Krass 2007^Citation21	Unclear	Unclear	Low	Low	Low	High	Low	Low	Unclear
Phumipamorn 2008^Citation22	Low	High	Unclear	Unclear	Low	Unclear	Low	Low	Unclear
Al Mazroui 2009^Citation23	Unclear	Unclear	Low	Low	Unclear	Unclear	Unclear	Low	Unclear
Edelman 2010^Citation1	Low	Unclear	Low	Low	Unclear	High	Low	Low	Unclear
Farsaei 2010^Citation24	Unclear	Unclear	Low	Low	Unclear	Unclear	Unclear	Low	Unclear
Jameson 2010^Citation2	Low	Low	Low	Low	Low	High	Unclear	Low	Unclear
Kirwin 2010^Citation36	Unclear	Unclear	High	Low	Unclear	Unclear	High	High	Unclear
Taveira 2010^Citation37	Low	Unclear	High	High	Unclear	Unclear	Unclear	High	Unclear
Cohen 2011^Citation26	Unclear	Unclear	Low	Low	Low	Unclear	Low	Low	Unclear
Mehuys 2011^Citation27	Low	Unclear	Low	Low	Unclear	Unclear	Unclear	Low	Unclear
Obreli-Neto 2011^Citation3	Low	Unclear	Low	Low	High	High	Unclear	Low	Unclear
Simpson 2011^Citation28	Low	Unclear	Low	Low	Unclear	Low	Low	Low	Low
Siriam 2011^Citation29	Unclear	Unclear	Low	Low	Low	Low	Unclear	Low	Unclear
Ali 2012^Citation30	Low	Low	Low	Low	Low	Unclear	Low	Low	Unclear
Chan 2012^Citation31	Low	Low	Low	Low	Unclear	Unclear	Unclear	Low	Unclear
Jacobs 2012^Citation32	Low	Unclear	Unclear	Unclear	Unclear	Unclear	Unclear	Low	Unclear
Jarab 2012^Citation4	Low	Unclear	Low	Low	Low	Unclear	Unclear	Low	Unclear
Kraemer 2012^Citation5	Low	Unclear	Low	Low	Unclear	Unclear	Unclear	Low	Unclear
Mahwi 2013^Citation6	Low	Low	Low	Low	Unclear	Unclear	Unclear	Low	Unclear
Mourao 2013^Citation33	Low	Unclear	Low	Low	Low	Unclear	Unclear	Unclear	Unclear
Samtia 2013^Citation7	Unclear	Unclear	Low	Low	Unclear	Unclear	Unclear	Low	Unclear
Chung 2014^Citation39	Unclear	Unclear	Low	Low	Low	Low	Low	Unclear	Unclear
O’Connor 2014^Citation34	Low	Low	Low	Low	Low	Low	Unclear	Low	Unclear
Cani 2015^Citation8	Unclear	Unclear	Low	Low	Low	Low	Unclear	Low	Unclear
Jahangard-Rafsanjani	Low	Low	Low	Low	Low	Low	Unclear	Low	Unclear
2015^Citation9
Wishah 2015^Citation10	Low	Low	Low	Low	Low	Low	Unclear	Low	Unclear
Chen 2016^Citation35	Low	Low	Low	Low	Unclear	Unclear	Unclear	Low	Unclear
Lim 2016^Citation11	Unclear	Unclear	Low	Low	Low	Low	Unclear	Low	Unclear

Abbreviation: EPOC, Effective Practice and Organization of Care.

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 Google Scholar

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 PubMedGoogle Scholar

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 PubMed Web of Science ®Google Scholar

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