Digital Health Interventions by Clinical Pharmacists

Digital Health Interventions by Clinical Pharmacists: History

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Subjects: Health Care Sciences & Services

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Integrating digital interventions in healthcare has gained increasing popularity among clinical pharmacists (CPs) due to advances in technology. Although the impacts of telephone-based interventions on patients’ outcomes were decidedly mixed, web-based interventions and mobile apps exerted generally positive influences.

clinical pharmacists
digital interventions
systematic review

1. Introduction

The last several decades have witnessed seismic advances in information technology. Technology evolution has facilitated the integration of digital technology into healthcare. For example, healthcare professionals (HCPs) now use their mobile devices for their work in daily practices [1]. Using their smartphone or tablet computer, HCPs can easily access patient charts, communicate with patients, and monitor disease management [2,3,4]. With the increasing use of smartphones, a number of HCPs have also adopted mobile applications (hereafter, ‘mobile apps’) in their practice. Approximately 77% of medical school healthcare professionals and students reported using at least one mobile app regularly, with 50% using their favorite app daily [5]. Mobile devices and apps are extensively used among HCPs during the conduct of their healthcare provision primarily because they are portable and easily accessible. In addition, digital healthcare provides benefits to patients when HCPs can provide timely interventions from a remote location. In this regard, digital healthcare is particularly helpful for individuals living in rural areas who may have limited access. Furthermore, technology-integrated interventions can benefit the elderly who may have limited personal and societal resources. Studies have shown that digital intervention resulted in health benefits [6] and an increase in digital competences [7] among older adults. For all of these reasons, integrating digital technologies in healthcare has attracted increasing attention.

As HCPs, pharmacists have shown interest in using digital technology in their practices [8,9,10]. For example, pharmacists have used personal digital assistance (PDA) as a tool for documenting their interventions, performing health assessments, providing patient education, and monitoring patient outcomes [11,12]. Pharmacists can also use systems with video cameras to approve prescriptions written at a remote site [13]. Each of these prior studies provided piecemeal evidence that showed how pharmacists employed digital technology in their practice.

2. Digital Health Interventions by Clinical Pharmacists

2.1. Telephone-Based Intervention

15 studies used a telephone as an intervention tool by clinical pharmacists. The impacts of the phone-based interventions on patients’ outcomes were mixed. Of these 15 studies, five studies reported significant effectiveness of the phone interventions [17,18,19,20,21]. Specifically, such interventions showed positive effects on lowering serum uric acid (sUA) levels among individuals with gout [17], the number of drug-related problems among those visiting outpatient cardiology clinics [18], mortality among those using five or more prescription drugs [19], and improved control of both BP [20] and international normalized ratio (INR) among patients discharged on warfarin [21]. However, five other studies showed no significant differences in outcomes between the treatment group who received phone-based interventions and the control group receiving usual care [22,23,24,25,26]. Specifically, no significant differences were reported between these two groups in these studies with respect to the proportion of individuals who attempted tobacco cessation among tobacco users [22], adherence to cancer drug for almost all cycles, overall survival (OS), and progression-free survival (PFS) among individuals with metastatic colorectal or gastric cancer [23], changes in HbA1c level and adherence to diabetic drugs [24], adherence to cardiovascular drugs and the percent of those with LDL-C goal achievement among individuals with coronary heart disease (CHD) [25], and the proportion of emergency department (ED) visits and readmission to hospital within 30 days of discharge among those with cancer [26]. Five studies revealed inconsistent effects of phone intervention on patients’ outcomes [27,28,29,30,31]. In other words, the interventions in each of these studies resulted in improvement in some outcomes, but not in others. For example, Bosworth et al. found that telephone intervention by clinical pharmacist specialists significantly reduced total cholesterol at 6 months in the treatment group, but no significant differences were found in CVD risk, sBP, dBP, LDL, HDL, BMI, HbA1c at 6 or 12 months, and total cholesterol at 12 months between the treatment and the control groups [27]. In Carter et al.’s study, telephone-based medication therapy management (MTM) services significantly improved individuals’ adherence to the American Heart Association (AHA)’s clinical guidelines, but their levels of BP, HbA1c, and lipids were not significantly different compared to those receiving usual care [28].

2.2. Web-Based Intervention

Two studies examined the impacts of web-based interventions by clinical pharmacists on patients’ outcomes [32,33]. In both studies, the interventions exerted positive influences on most of the outcomes examined. In Green et al.’s study, the treatment group received home BP monitoring and web services as well as web-based communications with pharmacists while the control group received only either home BP monitoring plus web services or usual care [32]. This study found significant improvements in most of the outcomes such as sBP, dBP, the percent of individuals with controlled BP (<140/90 mmHg), and the number of antihypertensive agents and aspirin used in the treatment group. They found no significant differences only in BMI change between the two groups. In Magid et al.’s study, the treatment group received web-based BP monitoring and education by pharmacists whereas the control group received usual care [33]. They also reported significant improvements in most of the outcomes—i.e., achievement of BP goal, sBP, dBP, and antihypertensive medication intensity; however, adherence to antihypertensive medications was not significantly different between the two groups.

2.3. Mobile-Based Intervention

Two studies from the same clinical trial included a mobile-based intervention to investigate the impact of this intervention on patients’ outcomes [34,35]. In this trial, a mobile app was developed to monitor and manage medication therapy for kidney transplant recipients. In these two studies, the intervention group received the mobile app-based intervention whereas the control group received usual care. The studies showed significant reductions in medication errors, incidences of grade 3 or higher adverse events (AEs), hospitalization [34], and tacrolimus intrapatient variability (IPV) in the treatment group [35]. However, no significant differences were found in incidences of grade 1 or 2 AEs and the infection rates between the two groups [35].

3. Summary

Overall, the impacts of telephone-based interventions in the studies were inconsistent: five studies showed benefits from these interventions, another five studies revealed no significant effects, and the remaining five studies reported mixed effects from the interventions. Web-based interventions resulted in positive impacts on changes in lab values (e.g., sBP, dBP) and health service use (e.g., antihypertensive drug and aspirin use) in patients with hypertension. Clinical pharmacists’ use of mobile apps significantly improved drug-related outcomes (e.g., reduction in medication errors and severe AEs) and health service use (e.g., reduction in hospitalizations) in kidney transplant recipients. When the study results were analyzed by the types of outcomes, we found that digital interventions were generally effective in lowering health service use (e.g., hospitalization, drug use) and improving drug-related outcomes (e.g., medication errors, AEs). However, they did not always result in significant improvements in other outcomes such as changes in lab values, adherence, survival, and health-related risk.

Physicians use medical apps for many reasons such as searching relevant literature, accessing patient charts, submitting electronic prescriptions, and monitoring disease management [2,3,4]. Pharmacists can also consider more novel technologies such as mobile apps, social media, and wearable devices for their patients where pharmaceutical care is provided. By using more diverse technologies, pharmacists could improve patients’ outcomes in additional domains.

The pharmacists provided their interventions to extensive populations such as patients with CHD, hypertension, hyperlipidemia, diabetes, cancer, gout, kidney conditions, tobacco use, using warfarin, and those using five or more drugs for chronic conditions. Accordingly, the purposes of providing these interventions were also very comprehensive, ranging from improving lab values (e.g., blood pressure, HbA1c), adherence, drug-related outcomes, and survival to lowering health service use and health-related risks. Of note, community pharmacists used digital interventions to serve somewhat limited purposes. Crilly and Kayyali found that community pharmacists’ interventions focused primarily on improvement in medication counseling and adherence, which represents traditional roles of the community pharmacist [14]. Crilly et al. argued that community pharmacists using more diverse technologies such as social media and mobile apps could help define their roles for more diverse outcomes/domains such as weight management, sexual health, and alcohol use [37]. Findings from both our study and their study suggest that digital interventions by clinical pharmacists are more likely to serve more various purposes compared to those interventions by community pharmacists. Nevertheless, community pharmacists are easily accessible professionals who routinely encounter people in their community. In this sense, digital care services are conveniently designed and efficiently delivered by community pharmacists, which can ultimately result in positive outcomes for patients.

Although digital interventions have gained increasing popularity, there has been little investigation into the cost-effectiveness (CE) of these interventions. Accordingly, whether a digital intervention is cost-effective remains to be elucidated. For example, Pyne et al. investigated the cost-effectiveness of a telemedicine-based collaborative care intervention for individuals with depression in rural areas [38]. They found the incremental cost-effectiveness ratio (ICER) of this intervention to be about $86,000/quality-adjusted life year (QALY) gained, which suggests that the intervention may or may not be cost-effective depending on the cost-effectiveness threshold. Another study conducted by Painter et al. evaluated the cost-effectiveness of telemedicine-based collaborative care for veterans with posttraumatic stress disorder (PTSD) in rural areas [39].

In summary, clinical pharmacists’ digital interventions were limited to the use of telephones, web tools, and mobile apps. In future studies, clinical pharmacists should consider novel technologies such as social media and wearable devices for patients who receive pharmaceutical care. Additionally, future studies need to be carefully designed by taking the contents of the intervention and the study population into account because these aspects are strongly related to the outcomes of the intervention.

This entry is adapted from the peer-reviewed paper 10.3390/ijerph19010532

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