Pharmaceutical Care Services for Patients With Diabetes: A Systematic Scoping Review

ABSTRACT

Objectives: Diabetes is a major chronic health issue that continues to grow rapidly on a global level. Pharmacists are highly trusted and accessible health care providers. This systematic scoping review of the scholarly peer-reviewed published literature was performed to qualitatively synthesize evidence on all potential pharmaceutical care services that could be offered by pharmacists while caring for patients with type 1 and type 2 diabetes.

Study Design: Systematic scoping review.

Methods: We conducted a systematic scoping review of the PubMed, Cochrane, ScienceDirect, and Google Scholar databases from inception to June 2020 using Medical Subject Headings and keywords relevant to diabetes and pharmaceutical care services. Quality of the articles was appraised using the appropriate critical appraisal tools. Data collected on pharmaceutical care services were synthesized qualitatively.

Results: A total of 56 articles were included in this systematic scoping review. A total of 86 pharmaceutical care services were qualitatively summarized. Services were related to screening for/prevention of diabetes (2.3%), supporting patients (7.0%), taking history (3.5%), patient education (17.4%), assessment/designing care plans (10.5%), efficiency (3.5%), collaboration (2.3%), identification/resolution of medication-related problems (26.7%), dispensing (7.0%), patient adherence (4.7%), saving costs (7.0%), monitoring/improving outcomes (5.8%), and follow-up (2.3%). Blinded randomized controlled trials and precise estimation of the effect of pharmacist interventions in caring for patients with type 1 and type 2 diabetes are needed.

Conclusions: Pharmacists are increasingly included in multi–health care professional teams. Pharmacists are providers of pharmaceutical care services that can improve pharmacotherapy, reduce costs, and improve quality of life of patients with diabetes.

Am J Manag Care. 2022;28(9):e339-e346. https://doi.org/10.37765/ajmc.2022.89227

Takeaway Points

Major databases were systematically searched for articles reporting on pharmaceutical care services for patients with diabetes, and 86 pharmaceutical care services were qualitatively synthesized.

• Pharmacists are increasingly included in multi–health care professional teams in health systems around the world.
• Pharmaceutical services were shown to improve health outcomes of patients with diabetes.
• Pharmaceutical services (n = 86) that can be offered to patients with diabetes were qualitatively synthesized.
• Findings of this review might be helpful in improving pharmaceutical care services for patients with diabetes.

The incidence of diabetes has been rising worldwide over the past several decades due to obesity, lack of exercise, smoking, and unhealthy diets rich with carbohydrates and fats.¹ According to the estimates of the International Diabetes Federation, about 463 million individuals were living with diabetes around the world in 2019.²

Pharmacists are increasingly included in multi–health care professional teams. The mission of the pharmacist is provision of pharmaceutical care, which can be defined as direct, responsible provision of drug-related care for the goal of achieving specific outcomes that can improve the quality of life of the patient. Results of previous studies have shown that pharmaceutical care services improved pharmacotherapy, glycemic control, lipid profile, and quality of life of patients with diabetes.^3,4

As scholarly peer-reviewed articles reporting on the role of pharmacist in caring for patients with diabetes accrue, there is a need to identify, summarize, and qualitatively synthesize evidence on the potential pharmaceutical care services that pharmacists can provide to patients with type 1 and type 2 diabetes. A systematic scoping review of the peer-reviewed literature on the role of pharmacists in caring for patients with type 1 and type 2 diabetes had not yet been conducted. Therefore, we undertook this systematic scoping review to analyze the literature published on the roles of pharmacists in caring for patients with type 1 and type 2 diabetes. Another aim of this systematic scoping review was to qualitatively synthesize evidence on all potential pharmaceutical care services that could be offered by pharmacists while caring for patients with type 1 and type 2 diabetes.

METHODS

This review was conducted and reported in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Adherence to the statement is shown in eAppendix Table 1 (eAppendix available at ajmc.com). The protocol of this systematic scoping review was registered in Open Science Framework (Center for Open Science) as registration doi:10.17605/OSF.IO/5X4GY.

Search Strategy

To identify relevant articles, 4 electronic databases were searched: PubMed, Cochrane Library, ScienceDirect, and Google Scholar. The search strategy was adopted for each database using Medical Subject Headings and relevant keywords. The search strategy is shown in eAppendix Table 2. The search syntaxes were created through combining the keywords using AND OR functions. The protocol of this search was informed by previous systematic searches.^5-7 The search was conducted to include articles indexed up to and including May 1, 2021. A back snowballing approach was conducted as a secondary search within the references of the articles that were identified through the database search to identify more potential studies that could be selected and included.⁸

Selection of the Articles

Three investigators (F.T., R. Salah, and S.R.), who were final-year Doctor of Pharmacy students, conducted the literature search through the databases. The search was supervised by the senior investigator (R. Shawahna), who was trained to conduct a literature search through the databases used in this study by a senior librarian. The search strategy was reviewed by a senior librarian before it was applied in this study. Studies identified through the databases were imported as research information systems documents that could be opened in EndNote (Clarivate Analytics) and comma-separated values files that could be opened using Microsoft Excel (Microsoft Inc).^9,10 The duplicate studies were removed. Three investigators (F.T., R. Salah, and S.R.) screened the identified studies against the inclusion and exclusion criteria. Discrepancies were resolved by discussion and consensus among the 3 researchers and the supervisor. Three investigators (F.T., R. Salah, and S.R.) screened the titles and abstracts of the identified studies that would be selected for a full-text review. Again, discrepancies were resolved by discussion and consensus among the 3 investigators and the supervisor.

Inclusion and Exclusion Criteria

Studies were candidates for a full-text review if they were related to pharmaceutical care services in diabetes. Priority for inclusion was given to studies reporting on the roles and services provided by pharmacists to patients with diabetes. The search was not restricted to a specific country of origin, year of publication, or publication status. Studies were excluded when they were reported in languages other than English, did not report on the role of pharmacists, or were not relevant to diabetes. Poster presentations in conferences, letters to the editors, and editorials were excluded.

Quality Appraisal

The quality of each article was appraised using the appropriate critical appraisal tool of the Critical Appraisal Skills Programme.¹¹ The quality of each article was appraised by 3 investigators (F.T., R. Salah, and S.R.) independently. Discrepancies were resolved by discussion and consensus among the 3 investigators and the supervisor.

Data Extraction and Synthesis

Three investigators (F.T., R. Salah, and S.R.) reviewed the full text of the selected studies independently. The investigators used text highlight tools and sticky notes to identify and mark the text on pharmaceutical services, pharmacist interventions, or recommendations for patients with diabetes. Discrepancies were resolved by discussion and consensus among the 3 investigators and the supervisor.

A data extraction form was specifically created for this study using Microsoft Excel. The data extraction form is shown in eAppendix Table 3. The 3 investigators (F.T., R. Salah, and S.R.) identified the relevant information needed for data collection independently. To ensure reproducibility, the process was repeated. Discrepancies were resolved by discussion and consensus. The text was analyzed and items relevant to pharmaceutical services, pharmacist interventions, or recommendations for patients with diabetes were collected. Because of the heterogeneous nature of the data, the results were presented as qualitative synthesis.^9,10

RESULTS

Articles Included

After removing the duplicates, a total of 257 articles were identified. Upon initial screening, 107 articles were excluded. After screening against the inclusion and exclusion criteria, 94 articles were excluded. The excluded documents were editorials, letters to the editor, conference presentations, non-English articles, and those lacking pharmaceutical care services in diabetes. A total of 56 articles were included in the scoping analysis. Of those, 41 (73.2%) were research articles and 15 (26.8%) were review articles. Further, of the 56 articles included, 10 (17.9%) reported interventions by clinical pharmacists, 23 (41.1%) reported interventions by community pharmacists, 6 (10.7%) reported collaborative services, 12 (21.4%) reported on adherence, and 5 (8.9%) reported on counseling. A summary of the included studies is provided in eAppendix Table 4. The selection process is shown in the Figure. Detailed characteristics of the selected articles are shown in the eAppendix.

Quality Appraisal

Articles reporting original studies, systematic reviews, and cohorts were assessed for quality using the appropriate tools. All articles included had acceptable quality in most of the domains. The majority of the studies lacked blinding and precise estimates of the effect of the intervention. Some of the systematic reviews lacked reporting of precise results and some cohort studies lacked reporting of confounding factors and precise results. Case-control studies lacked reporting of precise effects of the treatment. Results of the quality appraisal are shown in eAppendix Table 5.

Roles of Pharmacists in Caring for Patients With Diabetes

A total of 86 pharmaceutical care services were qualitatively summarized. Services were related to screening for/prevention of diabetes (2.3%), supporting patients (7.0%), taking history (3.5%), patient education (17.4%), assessment/designing care plans (10.5%), efficiency (3.5%), collaboration (2.3%), identification/resolution of medication-related problems (26.7%), dispensing (7.0%), patient adherence (4.7%), saving costs (7.0%), monitoring/improving outcomes (5.8%), and follow-up (2.3%). Details are provided in the Table [part A and part B].

DISCUSSION

This systematic scoping review sought to identify and summarize scholarly peer-reviewed articles reporting on pharmaceutical care of patients with type 1 and type 2 diabetes. To the best of our knowledge, this is the first systematic scoping review of the scholarly peer-reviewed literature on pharmaceutical care of patients with type 1 and type 2 diabetes. The study findings will prove informative to decision makers in health care organizations who need to make appropriate decisions about integrating pharmacists into multi–health care provider teams who care for patients with type 1 and type 2 diabetes, or who are expanding pharmaceutical services.

The studies included in this systematic scoping review focused on care services provided by pharmacists to patients with type 1 and type 2 diabetes.^12-15

Screening for and Prevention of Diabetes

Today, pharmacists can play a vital role in screening for risk factors and identifying individuals who are at risk of developing diabetes.¹⁶ Contemporary pharmacies are well equipped with advanced tools that can be used to measure weight, height, blood glucose, hemoglobin A_1c, blood pressure, and lipid profile including total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides.¹⁷ Pharmacists can also play a vital role in educating individuals on how to mitigate their risk factors and reduce their risk of developing diabetes in the future. Once indicators that warrant attention are identified, pharmacists can refer the patients to seek formal screening and diagnostic services in specialty care.¹⁸ These practices can promote early diagnosis, improve management, and delay onset of complications associated with diabetes.¹⁹

Supporting Patients Through Effective Relationships

Pharmacists are highly accessible and trusted health care providers.³ During their education/training, pharmacists learn how to warmly greet their patients, make them feel comfortable, pay attention to their health care needs, listen, and answer their questions.²⁰ Patients often have fears and negative perceptions about their diabetes. Pharmacists can address these negative perceptions by reassuring patients and providing them with emotional support. These services have been shown to improve patients’ quality of life.²¹

Taking History

Pharmacists can take complete and reliable medication histories from their patients. These histories are vital in informing lifestyle and pharmacotherapeutic interventions.¹⁹ Pharmacists are also competent in conducting medication reconciliations. Access to complete patient information has been shown to facilitate the design of suitable care plans, making recommendations, and/or amending care plans.²²

Patient Education

Education about diabetes. Pharmacists can play an important role in educating patients about their diabetes, what complications are associated with unmanaged diabetes, how to live and cope with diabetes, how to monitor blood glucose levels, and how to prevent/delay the incidence of complications.^23,24 It has been argued that well-informed patients are more likely to achieve glycemic control.^19,25,26

Education about antidiabetic medications. Pharmacists are experts in medications and can educate patients on how to get the most benefit out of their medications.²³ Pharmacists have designed appropriate interventions to increase patients’ general attentiveness to their medications: when to use them, how to use them, how to store them, what adverse effects could be associated with them, and what medications, herbs, and foods to avoid while taking them.^27,28

Education about lifestyle modifications. Pharmacists can educate patients on how to lead a diabetes-compatible lifestyle, including, for instance, a healthy diet, regular exercise, weight control, and smoking cessation.¹⁹ Some patients can adequately control their blood glucose with lifestyle modifications and decrease their dependence on antidiabetic medications.²⁹

Education about self-management. Pharmacists can also educate patients how to self-manage their diabetes. Patients can learn how to adequately use home monitoring devices, such as glucometers and digital blood pressure monitors, and how to keep track of and document their home readings.¹⁶ Patients can learn what ranges are considered normal or target and when to seek medical advice.²⁷ Pharmacists can also teach their patients, especially those with type 1 diabetes, how to recognize, avoid, and/or manage states of hypoglycemia.

Assessment of Patients and Designing Care Plans

Pharmacists help assess patients with diabetes based on their history and laboratory tests to initiate, adjust/modify/optimize, and/or discontinue mediation therapy.³⁰ In modern health care delivery, patients’ cases are presented in multidisciplinary health care team discussions in which pharmacists actively participate. Often, the best care plan decisions are those made jointly.¹⁹

Individualized Care Plans

Individualized pharmaceutical services should be designed and provided to patients after a complete discussion of their medical, family, and social history; laboratory findings; glycemic control; comorbid conditions; and macrovascular and microvascular complications.²⁴ Individualized care plans have been advocated as a useful approach to effectively address patients’ specific health care needs.^19,31

Efficiency in Providing Services

In modern health care systems, pharmacists have several roles and responsibilities that, when performed efficiently, have been shown to improve the quality of care provided to patients; this has translated into improved glycemic control and delaying short-term and long-term complications of diabetes.^32,33

Collaboration With Other Health Care Providers

Study results have shown that including pharmacists in the care team often results in improved medication management, optimization of medication regimens, reduction of medication-related problems, and easier achievement of therapeutic goals.^30,34,35 Additionally, inclusion of pharmacists was shown to complement the expertise of other health care providers and enable provision of comprehensive management and referral services to patients with diabetes.³⁶

Identification and Resolution of Medication-Related Problems

Patients may experience medication-related problems, which pharmacists, as experts in medications, can help identify and resolve.¹⁹ These problems can include inappropriate doses; the method, timing, frequency, or duration of administration; dosage form; misspelled medication orders; adverse drug reactions; allergies; drug-drug, food-drug, and drug-disease interactions; and cost of therapy.^37,38 Resolving these problems can reduce patient mortality and morbidity, save costs, and improve efficiency of the health care system.

Dispensing Medications

Dispensing medications is one of the classical roles of pharmacists in all health care systems.³⁹ Before dispensing, pharmacists review the medication orders for their validity. Pharmacists should dispense the correct drug product, dose, amount, and package.⁴⁰

Improving Patient Adherence to Medications

Pharmacists can help assess patients’ adherence to their antidiabetic medications at the right dosage, frequency, and timing.⁴¹ Pharmacists can address promoters of nonadherence and improve adherence by forming a good rapport with patients and providing comprehensive education/counseling on patients’ antidiabetic medications. They can frankly discuss the consequences of nonadherence, thus improving patients’ commitment to taking their medication.^42,43 Adherence to taking medications has been shown to improve glycemic control.

Saving Costs

Study results have shown that patients are less likely to adhere to their medications when the costs of the medications are high.^44,45 Pharmacists can refer patients to sources that provide free medications to those who are unable to afford them.³ Whenever possible, pharmacists should attempt to modify the care plan and substitute some medications with more affordable alternatives after consultation with the prescribers.

Monitoring and Improvement of Patient Outcomes

Pharmacists can review patient health records, assess patients’ adherence to their medications, and monitor their health-related outcomes.³¹ Such pharmaceutical services have been shown to help patients achieve therapeutic goals, reduce incidence of complications that are associated with nonadherence, and improve their satisfaction, quality of life, and how well they cope with their disease.³ Improving glycemic control and patient outcomes has been shown to reduce emergency and hospital admissions, health care–associated costs, morbidity, and mortality among patients with diabetes.^19,46

Follow-up

A pharmacist can schedule visits or telephone calls to follow up with patients and educate/counsel them regarding their medications, screen for medication-related problems, and ensure adherence to medications, diet, and lifestyle.⁴⁷ The pharmacist can also remind patients to attend their scheduled laboratory tests and visits to their health care providers for foot, eye, kidney, cardiovascular, and neurologic checks.^30,47,48

Strengths and Limitations of the Study

Results of this systematic scoping review can be interpreted after considering a number of strengths and limitations. First, this is the first systematic scoping review with qualitative synthesis on the pharmaceutical care services provided to patients with type 1 and type 2 diabetes. Systematic scoping reviews with qualitative synthesis are particularly important in summarizing and synthesizing evidence—in this case, on the role of pharmacists in caring for patients with type 1 and type 2 diabetes. Second, the databases PubMed, Cochrane, ScienceDirect, and Google Scholar were extensively searched in this study. These databases index authentic scholarly journals in the field. Third, because the search strategy was not restricted to a certain study design such as randomized controlled trials, a wide coverage of the subject under investigation was possible. Fourth, the articles included in this study were of acceptable quality as shown by the quality appraisal. Quality appraisal is not often conducted in scoping reviews. However, because this study was a systematic scoping review with qualitative synthesis, quality appraisal was conducted. Finally, 3 researchers conducted all steps of the study and a fourth senior researcher oversaw all the stages of the study. This should have added rigor to the methodology used in this study.

On the other hand, this study is not without limitations. First, the articles included in this review were in English only. Although this presumably reduced the bias brought about by incorrect translation, it also could have resulted in exclusion of some important findings published in languages other than English. Second, results of this study were synthesized qualitatively. Meta-analysis is often conducted to pool evidence from quantitative studies. In this study, a systematic scoping review approach was followed to summarize, discuss, and qualitatively synthesize the roles of pharmacists in caring for patients with type 1 and type 2 diabetes.⁴⁹ Third, clinical trial registries were not systematically searched to identify registered studies with reported results that could be used in this review. It is worth mentioning that the aim of this study was to review only scholarly, peer-reviewed, published articles. Finally, we did not search subscription-based databases such as Scopus and Web of Science; doing so would have resulted in a larger number of articles. However, the databases searched in this study index a large number of scholarly sources on pharmaceutical care of patients with type 1 and type 2 diabetes.

CONCLUSIONS

Pharmacists are increasingly included in multi–health care professional teams. Pharmaceutical care services and pharmacist interventions were shown to improve glycemic control, patient satisfaction, and quality of life. Additionally, pharmaceutical care services and pharmacist interventions were shown to reduce complications of diabetes, health care–associated costs, morbidity, and mortality among patients with diabetes.

Acknowledgments

The authors would like to thank An-Najah National University for making this study possible.

Author Affiliations: Department of Physiology, Pharmacology, and Toxicology, Faculty of Medicine and Health Sciences, An-Najah National University (RSh), Nablus, Palestine; An-Najah BioSciences Unit, Centre for Poisons Control, Chemical and Biological Analyses, An-Najah National University (RSh), Nablus, Palestine; Doctor of Pharmacy Program, Department of Pharmacy, Faculty of Medicine and Health Sciences, An-Najah National University (FT, RSa, SR), Nablus, Palestine.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RSh); acquisition of data (RSh, FT, RSa, SR); analysis and interpretation of data (RSh, FT, RSa, SR); drafting of the manuscript (RSh, FT, RSa, SR); critical revision of the manuscript for important intellectual content (RSh, FT, RSa, SR); statistical analysis (RSh, FT, RSa, SR); provision of patients or study materials (RSh, FT, RSa, SR); administrative, technical, or logistic support (RSh, FT, RSa, SR); and supervision (RSh).

Address Correspondence to: Ramzi Shawahna, PhD, Department of Physiology, Pharmacology, and Toxicology, Faculty of Medicine and Health Sciences, New Campus, An-Najah National University, PO Box 7, Building 19, Office 1340, Nablus, Palestine. Email: ramzi_shawahna@hotmail.com.

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