Please send some peer-review (preferred) articles that demonstrate financial and clinical impacts of clinical pharmacists providing Comprehensive Medication Management (CMM) or medication therapy management (MTM) in ambulatory clinics.

Comment by InpharmD Researcher

There is an extensive body of ambulatory care literature evaluating the impact of clinical pharmacists providing comprehensive medication management (CMM) or medication therapy management (MTM), although reported economic and utilization outcomes are heterogeneous. Pharmacist-led medication review in ambulatory clinics is consistently associated with improved identification and resolution of drug-related problems, reductions in potentially inappropriate medications, and modest decreases in total medication counts, supporting a role in deprescribing among older adults; however, effects on hospitalizations and quality of life are more variable. Economic analyses suggest potential reductions in downstream healthcare and pharmaceutical costs, with some studies demonstrating favorable cost-effectiveness and return on investment depending on the payment model. Within value-based and population health frameworks, integration of pharmacists into team-based ambulatory care is associated with improved chronic disease control and, in some cohorts, reduced acute care utilization. Although direct comparative evidence between pharmacists and advanced practice providers (APPs) on CMM and MTM outcomes is limited, collaborative care models indicate that pharmacists can deliver effective medication management and may reduce primary care workload, supporting a complementary and potentially cost-efficient role. Please refer to the accompanying tables and summaries for detailed quantitative clinical and economic outcomes.

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Background

A 2019 review evaluates health economics evidence based on 11 randomized controlled trials of pharmacist-led medication review in pharmacotherapy managed cardiovascular disease risk factors, specifically hypertension, type-2 diabetes mellitus, and dyslipidemia, in ambulatory settings. Among 5 US-based studies conducted from 2001 to 2016, pharmacist-led interventions primarily consisted of a medication review with adherence counseling and a face-to-face interview with patients during follow-ups. Economic evaluations included cost-effectiveness, third payer, societal, and cost-utility. All studies conducted in the US reported favorable outcomes in blood pressure improvements, life years gained, quality-adjusted life year (QALY), or refill adherence, with life year incremental costs from individual studies ranging from $49.73 per patient to $432.1 per patient. The corresponding incremental cost-effectiveness ratio was determined to be $59.76 per QALY (one study), $1.66 per mmHg to $48.6 per mmHg for systolic blood pressure, $3.53 per mmHg to $105.4 per mmHg for diastolic blood pressure, and $1,964.1 (men) and $2,274.2 (women) per life year gained (one study). The wide span of years in which studies were conducted could have contributed to the considerable variations in monetary outcomes across studies. [1]

A 2015 meta-analysis assessed the effects of medication therapy management (MTM) services among outpatients with chronic illnesses. A total of 44 studies (21 randomized controlled trials, four non-randomized controlled trials, and 19 cohort studies) were included for analysis, all of which used pharmacists to deliver MTM services, specifically medication review, patient-directed education, care coordination, and opportunity for follow-up. Although the studies reported wide confidence intervals (CI), medication therapy management interventions reduced health plan expenditures on medication costs. After MTM interventions, patients with diabetes mellitus or heart failure had lowered odds of hospitalization (diabetes: odds ratio 0.91 to 0.93 based on the type of insurance; adjusted hazard rate for heart failure: 0.55; 95% CI 0.39 to 0.77) and hospitalization costs (mean differences ranged from -$363.45 to -$398.98). [2]

A 2021 systematic review of pharmacist-led interventions in ambulatory care settings included 31 studies (27 controlled trials and 4 observational studies) evaluating clinical, behavioural, economic, and humanistic outcomes. Clinical medication review was the most frequently studied intervention (61.29%), followed by adherence review (19.3%). Clinical medication review demonstrated favorable effects on clinical outcomes, particularly management of drug-related problems and adverse events, and contributed most to reductions in healthcare costs. Adherence review was most effective for improving medication adherence. In observational studies, adherence review was associated with 2% higher adherence (34.3% vs 32.3%), 1.8% fewer hospitalizations, 2.7% fewer emergency room visits, and lower total healthcare costs (−$226.07; all p<0.0001), and medication therapy management reduced plan-paid healthcare costs by 10.3% compared with a 0.7% increase in controls (p<0.05). In interventional studies, correction of identified drug-related problems reached 78.7% in intervention groups versus 0% in controls (p<0.001), and inappropriate medications decreased from 27.2% to 8.9% with pharmacist review (p<0.001). Collaborative pharmacist interventions also improved medication adherence and medication appropriateness index scores (median 8.0 vs 20.0; p= 0.001). However, effects on hospital admissions and quality of life were inconsistent or not significant. The authors concluded that clinical medication review can play a major role in managing drug-related problems and economic issues, while larger, standardized, and rigorously designed intervention studies are needed to support decision-making and confirm meaningful improvements in patient care. [3]

A 2024 qualitative systematic review and meta-synthesis included 9 qualitative studies involving 235 stakeholders (general practitioners, specialist physicians, pharmacists, nurse practitioners, patients, carers, and clinic staff) examining perspectives on pharmacist involvement in deprescribing in ambulatory care settings. Four overarching themes were identified: therapeutic impetus and status quo mentality, role and responsibility, multidisciplinary care, and conflicting interests in pharmacy practice. Stakeholders generally supported pharmacist involvement in deprescribing but reported multiple barriers, including unclear role responsibility, prescriber authority concerns, limited communication and care fragmentation, lack of access to clinical information, insufficient guidelines or deprescribing resources, patient resistance to medication changes, and lack of reimbursement or time for deprescribing activities. Enablers included collaborative relationships with prescribers, embedding pharmacists within clinics, regular medication review processes, improved communication and shared decision-making, and increased access to deprescribing resources. Overall, pharmacists were viewed as a valuable but underutilized contributor to deprescribing in ambulatory care; improving accessibility, communication with pharmacists, and trust in their professional role were identified as key strategies to support safe and successful deprescribing and improve patient outcomes. [4]

A 2016 article describes the economic outcomes of an ambulatory care clinic-based practice composed of pharmacists within a large academic health system in North Carolina. Pharmacists, designated as clinical pharmacists practitioners (CPP), were authorized to provide collaborative drug therapy management services, including medication prescribing and ordering of laboratory tests according to defined protocols under physician supervision. Among patients served over seven months ending in March 2014, the hospital readmission rate was 6.5% for patients seen by a CPP within 30 days of hospital discharge versus a rate of 20% for those not seen by a CPP. During the same period, patients served by the general internal medicine clinic’s hospital follow-up program (coordinated by a CPP) had an all-cause 30-day hospital readmission rate of 9% compared to 26% with the usual care. One 30-day hospital readmission was avoided for every seven patients seen in the clinic, equating to prevention of 102 readmissions annually with an estimated cost reduction of $1,113,000. [5]

A 2015 proof-of-concept, nonrandomized study assessed the impact of a comprehensive pharmacist-managed medication therapy management (MTM) program in a private endocrinology practice on healthcare utilization and costs in patients with diabetes following a transition of care. Eligible participants were adults with type 1 or 2 diabetes and a recent acute care episode, including hospitalizations or emergency department visits. From 2012 to 2013, 28 intervention patients received pharmacist-led MTM across four visits over six months, while 73 historical controls were identified from electronic medical records spanning 2008 to 2012. The primary endpoint was the 30-day hospital readmission rate for the primary cause of the index admission, and secondary endpoints encompassed cumulative utilization rates for all-cause hospitalizations, emergency department visits, urgent care encounters, and paramedic visits at various time points (30, 60, 90, and 180 days) post-discharge. Additionally, total healthcare costs, including prescription medication expenses, were estimated at 180 days. Propensity score weighting was employed to balance covariates between the groups, and multivariate negative binomial regression models assessed utilization rates while generalized linear regression models analyzed log-transformed costs. [6]

Findings demonstrated that both groups had a 0% hospital readmission rate at 30 days post-discharge. However, the intervention group had a significantly higher utilization rate of urgent care/ED visits at 90 days post-discharge compared with the control group (0.19 vs 0.04; p = 0.06). Cumulative utilization rates for hospitalizations and acute care visits were not statistically different between groups across all follow-up time points, with an incidence rate ratio of 1.61 at 180 days (p=0.72). While the intervention group exhibited a lower mean total cost at 180 days ($29,664 vs $33,547 in controls), the difference was not statistically significant (cost ratio= 0.73, p= 0.20). A matched subset analysis showed a trend toward reduced pharmacy costs in the intervention group but did not reach statistical significance. The results suggest that pharmacist-led MTM in an ambulatory endocrinology setting did not significantly affect hospital readmissions or healthcare utilization over six months, warranting further investigation in larger, randomized trials with extended follow-up periods. [6]

A 2019 randomized clinical trial evaluated the impact of a pharmacist-provided MTM program on 30-day hospital readmission rates. Conducted across six hospitals and a supermarket pharmacy chain with 60 pharmacies, the study included 400 patients discharged with diagnoses of acute myocardial infarction, pneumonia, congestive heart failure, chronic obstructive pulmonary disease, or diabetes. Patients were randomized to receive either standard care or a pharmacist-led MTM intervention, which involved medication reconciliation, comprehensive medication review, adherence counseling, and patient education at a community pharmacy. The transition of care process was supported by a health information exchange that transmitted discharge summaries from hospitals to pharmacists. Pharmacists identified, documented, and resolved medication-related problems while coordinating with prescribers and patients. In the intention-to-treat analysis, no significant difference in 30-day readmission rates was observed between the intervention and control groups (11.3% vs. 10.7%; p= 0.49). However, a per-protocol analysis, which included the 62 intervention patients who attended their MTM appointment and 187 control patients, revealed a significant reduction in hospital readmissions (1.6% vs. 10.7%; p= 0.02). Logistic regression adjusting for baseline differences demonstrated that participation in the pharmacist-led intervention significantly lowered readmission risk (odds ratio [OR] 0.126; 95% CI 0.016–0.968; p= 0.046). Pharmacists conducted an average of six interventions per patient, including medication adjustments, adherence support, and therapy optimization, with an 82.6% acceptance rate from both patients and prescribers. Although primary medication nonadherence did not significantly differ between groups, secondary adherence, particularly to statins, improved in the intervention cohort (proportion of days covered > 80% in 60.5% vs. 37.5%; p= 0.04). High patient satisfaction scores further highlighted the acceptability of pharmacist-led transitions of care. [7]

A 2018 implementation study evaluated the impact of comprehensive medication management (CMM) on hospital readmission rates within a health system. The system implemented a care transition process in 2012, which included referrals to MTM pharmacists. Retrospective data from electronic medical records (EMRs) identified hospital admissions, with 43,711 patients and 57,673 hospitalizations included. Of these, 1,291 hospitalizations had a CMM visit within 30 days of discharge (median 6 days), forming the CMM cohort. Patients who received CMM had significantly lower 30-day readmission rates (8.6% vs. 12.8%; p<0.001). The 60-day readmission rate was also lower for CMM patients (15.6% vs. 17.6%), but this difference was not statistically significant (p= 0.0528). Stratification by readmission risk category showed that CMM patients had significantly lower 30-day readmission rates in the highest risk groups: Average (7.1% vs. 9.5%; p= 0.025), Elevated (9.9% vs. 21.4%; p<0.001), High (18.3% vs. 35.9%; p<0.001), and Extreme (36.4% vs. 77.7%; p= 0.006). Based on these findings, the study concluded that CMM, provided by MTM pharmacists, reduces the 30-day readmission rate and may have the greatest effect on patients at the highest risk of readmission. [8]

A 2019 study investigated the impact of pharmacist-led continuous care and electronic communication on 30-day hospital readmission rates among high-risk patients with chronic conditions. The investigation enrolled patients discharged from four hospitals within an integrated health system in Pennsylvania, focusing on those diagnosed with chronic obstructive pulmonary disease, heart failure, acute myocardial infarction, pneumonia, or diabetes. Patients receiving the intervention were provided medication management consultations by inpatient pharmacists before discharge, followed by structured communication via a secure messaging system to community pharmacists. After discharge, these patients engaged in up to five in-person or telephonic follow-up consultations with community pharmacists to reinforce adherence, identify medication-related issues, and optimize treatment regimens. A matched control cohort, selected using a 5:1 propensity-score matching process, received usual care without pharmacist-facilitated interventions. The findings demonstrated that patients who participated in both inpatient and community pharmacist interventions exhibited a significantly reduced 30-day hospital readmission rate (9% vs. 15%; p= 0.02) and lower all-cause 30-day mortality (2% vs. 5%; p= 0.04) compared to the matched control group. Additionally, a composite endpoint of readmission, emergency department visits, or death at 30 days was lower in the intervention arm (22% vs. 28%), though the difference did not reach statistical significance (p= 0.09). Time-to-event analysis illustrated that the intervention was associated with a reduced hazard of readmission within the first 30 days (hazard ratio 0.56, 95% CI 0.33-0.94); however, differences were no longer evident at 90 days. Economic analysis revealed an estimated return on investment of 8.1 based on total cost reductions in the first 30 days post-discharge. These findings suggest that integrating community pharmacists into transitional care through electronic communication is both feasible and effective in reducing early readmissions, mortality, and healthcare costs. [9]

A 2016 secondary analysis of data from a cluster-randomized controlled trial evaluated the impact of a telephonic MTM intervention on ED utilization in a Medicare-insured home health population. Conducted across 40 randomly selected, geographically diverse home health agencies, the study randomized 656 patients, with 297 receiving the intervention and 359 allocated to usual care. The intervention encompassed an initial telephonic medication reconciliation performed by a pharmacy technician, a comprehensive medication review conducted by a pharmacist via telephone, and subsequent pharmacist follow-up calls. The primary outcome was the incidence of all-cause ED utilization within 60 days of home health admission, with patients stratified into quartiles based on their baseline risk of ED utilization using a logistic regression model derived from CMS data. Multivariable logistic regression employing generalized estimating equations was used to determine the adjusted odds ratio (AOR) of ED utilization between intervention and usual care groups. The analysis found 24.4% of patients in the telephonic MTM group visited the ED compared to 25.1% in the usual care cohort, yielding an AOR of 1.11 (95% confidence interval [CI] 0.79 to 1.57), indicating no significant overall reduction in ED utilization with the intervention. However, among patients classified in the lowest risk quartile, ED utilization was significantly lower in the intervention group than in the usual care group (AOR 2.52; 95% CI 1.15-5.49; p= 0.02). These findings suggest that while telephonic MTM did not significantly decrease ED visits across the entire study population, it may offer a meaningful benefit among patients at lower risk for ED utilization. Further investigation into optimizing telephonic pharmacist interventions and incorporating caregiver engagement may enhance outcomes for higher-risk home health patients. [10]

A 2014 retrospective matched cohort study evaluated the impact of a Medicare MTM program on patient mortality, hospitalization, ED utilization, and daily prescription costs. A total of 34,532 patients who received MTM services between 2006 and 2010 were compared to 138,128 control patients who were enrolled in Medicare but did not receive MTM services. Patients were matched in a 1:4 ratio based on age, gender, geographic location, and diagnostic-cost-group (DxCG) risk score. The results showed that the MTM group had significantly reduced mortality (hazard ratio [HR] 0.86; 95% CI 0.84 to 0.88; p<0.001), lower odds of hospitalization (odds ratio [OR] 0.97; 95% CI 0.94 to 0.99; p= 0.018), and higher odds of ED visits (OR 1.17; 95% CI 1.14 to 1.20; p<0.001). There were no differences in the change in daily medication costs compared to the matched controls. A subgroup analysis of the 2010 cohort found similar results with better outcomes than the overall cohort. Due to these findings, it was suggested that Medicare MTM services resulted in lower mortality and hospitalization rates, but increased ED visits, with no changes in daily medication costs. [11]

A 2024 randomized controlled trial evaluated the impact of a multifactorial pharmacist-led intervention protocol (MPIP) on medication adherence and optimization in 192 patients with type 2 diabetes at an ambulatory healthcare center in the United Arab Emirates. Participants were randomly assigned to either the intervention or control group, with the MPIP incorporating MTM, face-to-face counseling, patient-specific medication booklets, and a mobile application. Medication adherence was assessed through the fixed medication possession ratio (MPR) and a validated medication adherence questionnaire. At the 12-month follow-up, the intervention group demonstrated a significant improvement in overall adherence, with a mean total MPR of 0.95 ± 0.09 compared to 0.92 ± 0.09 in the control group (p= 0.02). Furthermore, regimen-specific MPRs for antihyperglycemic, antihypertensive, and antihyperlipidemic medications showed superior adherence in the intervention group (p<0.01 for all regimens). The medication adherence questionnaire also indicated that 70.2% of participants in the intervention group achieved perfect adherence, compared to 48.9% in the control group. Results also demonstrated a notable impact on clinical interventions and medication optimization. Pharmacists in the intervention group carried out 41 interventions addressing drug-related problems, compared to only six in the control group, with a focus on dose adjustments, therapeutic substitutions, and deprescribing of medications with potential adverse effects. Additionally, usage of the mobile application and medication booklet increased from 41.5% to 45.7% and from 23.4% to 27.6%, respectively, in the intervention group, correlating with improved adherence. The integration of pharmacist-led strategies into routine ambulatory care workflow not only enhanced medication adherence but also facilitated more effective medication management for patients with type 2 diabetes, reinforcing the crucial role of pharmacists in optimizing chronic disease therapy. [12]

A 2021 investigation employed a decision analytic model to evaluate the cost-effectiveness of pharmacist-physician collaborative care models (PPCCMs) compared to usual care for managing hypertension from a payer perspective. This model incorporated a 3-year time horizon, utilizing data drawn from published literature and publicly available resources. The population comprised adults with a prior diagnosis of hypertension, defined by office-based blood pressure readings of ≥140/90 mmHg, or those receiving antihypertensive medications. The study utilized effectiveness data from two prior studies that evaluated the impact of PPCCMs on time in target range (TTR) for systolic blood pressure and its subsequent effects on four cardiovascular outcomes: nonfatal myocardial infarction, stroke, heart failure, and cardiovascular disease death. The analysis included direct medical costs, factoring in both program costs (provider time) and downstream healthcare utilization related to acute cardiovascular events. Results published in the same 2021 paper revealed that the PPCCM approach to hypertension management was associated with lower downstream medical expenditures (a difference of −$162.86) and reduced total program costs (a difference of −$108.00) compared to usual care. The model predicted that, for every 10,000 patients with hypertension managed using PPCCM over three years, approximately 27 cardiovascular disease deaths, 29 strokes, 21 nonfatal myocardial infarctions, and 12 cases of heart failure would be averted. The analysis suggested that PPCCMs not only reduce costs but also enhance cardiovascular outcomes by increasing the time patients spend with blood pressure in the target range. Consequently, this evidence indicates potential savings in downstream healthcare expenses, offering a compelling case for payer coverage of PPCCM services to improve patient outcomes and prevent future healthcare costs. [13]

Literature Review

A search of the published medical literature revealed 23 studies investigating the researchable question:

Level of evidence

A - Multiple high-quality studies with consistent results Read more→

Please see Tables 1-23 for your response.

Cost-Saving Medication Therapy Management for Outpatients
Design	Prospective cohort study N= 20,281 outpatient prescriptions
Objective	To evaluate the causes and monetary value of cost-saving prescription interventions made by clinical pharmacists in outpatient pharmacy
Study Groups	N/A
Inclusion Criteria	Not specified.
Exclusion Criteria	Not specified.
Methods	Outpatient prescriptions were randomly audited using a customized outpatient prescription audit tool integrated with computerized physician order entry. Drug-related problems were communicated to respective prescribers, and their response to each intervention was documented. Both unit dose cost and anticipated dose cost savings were calculated to evaluate the monetary benefit for patients.
Duration	Between August 2017 and June 2018
Outcome Measures	Monetary value of cost-saving
Baseline Characteristics	General data of the reviewed prescriptions	Medication errors, n (%)	Cost-effective intervention, n (%)	p-value
	Gender Male Female	123 (39.6%) 187 (60.3%)	49 (43.7%) 63 (56.2%)	0.452
	Age group 1-20 21-40 41-60 61-80 81-100	29 (9.03%) 106 (34.1%) 95 (30.6%) 78 (24.8%) 2 (0.64%)	6 (5.3%) 31 (27.6%) 35 (31.2%) 38 (33.9%) 2 (1.7%)	< 0.001
Results Anticipated and unit dose cost saved for drug-related problems	Primary domain	Causes (%)	Unit dose cost saved (International normalized ratio [INR])	Anticipated dose cost saved (INR)	p-value
	Drug selection	Inappropriate drug (within guidelines but otherwise contraindicated) (1.8%)	54.26	401.2	< 0.001
		No indication for drug (3.5%)	1,503.14	2,404.39
		Inappropriate combination of drugs or drugs and herbal medication (25.7%)	583.81	3,694.78
		Inappropriate duplication of therapeutic group or active ingredient (43.4%)	1,313.94	14,117.87
	Dose selection	Drug dose low (0.9%)	1,075	1,075	< 0.001
		Drug dose high (12.4%)	162.4	2,764.17
		Dosage regimen too frequent (8.8%)	134.89	2,028.27
		Dose-timing instructions wrong, unclear, or missing (0.9%)	23.63	94.52
	Treatment duration	Duration of treatment too short (0%)	0	0	< 0.001
	Treatment duration	Duration of treatment too long (1.8%)	24.66	310.6	< 0.001
	Unit dose cost of INR 4875.73 and anticipated dose cost of INR 26890.8 were saved from outpatients. Major contributory drug classes that reduced the cost of therapy were antibiotics (24.23%), proton-pump inhibitors (13.27%), and analgesics (12.34%). Prescribers' response to pharmacist intervention varied; 53% responded to stop the drug, 21% responded to change the brand, and 20% changed the frequency of administration.
Adverse Events	N/A
Study Author Conclusions	As clinical pharmacist has the expertise to detect, resolve, and prevent medication errors, the development of clinical pharmacy practice in a hospital outpatient pharmacy will have a significant impact on reducing prescription errors and health-care cost also.
Critique	The presented data only represents a single institution's experience. The study took place in India, in which presented cost savings may not be as relevant in the US outpatient settings.

References:
[1] Priya K, Sreshta M, Philip S. Cost-saving medication therapy management for outpatients. Perspect Clin Res. 2021;12(1):14-20. doi:10.4103/picr.PICR_164_18

Improving the Economic and Humanistic Outcomes for Diabetic Patients: Making a Case for Employer-Sponsored Medication Therapy Management
Design	Prospective, single-center, pre-post longitudinal study N= 101
Objective	To determine the cost savings of a pharmacist-led, employer-sponsored medication therapy management (MTM) program for diabetic patients and to assess for any changes in patient satisfaction and self-reported medication adherence for enrollees
Study Groups	Pre-joining: Office visit (n= 54) Emergency room visit (n= 23) Inpatient visits (n= 10) Post-joining Office visit (n= 67) Emergency room visit (n= 12) Inpatient visits (n= 3)
Inclusion Criteria	Employees, their spouses, and dependants whose primary provider of medical insurance and prescription coverage was the City of Toledo; diagnosed with type 2 diabetes; have been on medication or been administered a new prescription for the treatment; had appropriate means of transport to a participating site; be able to read and understand English.
Exclusion Criteria	Any patient not meeting any one of the inclusion criteria.
Methods	Patient visits and counseling sessions with pharmacists for the study period were staggered to take place at 2–4 weeks, and 3, 6, 9, and 12 months following the baseline visit. Economic costs were analyzed for patients whose data were available for the one-year study period. The pre-joining costs were calculated by obtaining all utilization costs for one year before entering the program. All post-costs were calculated for one year following enrollment. Utilization and associated costs were identified by the number and cost of physician office visits, emergency room visits, and inpatient visits or hospitalizations. Total costs were defined as the sum of the aforementioned three different forms of health care utilization.
Duration	January 15, 2008, to September 1, 2010 Follow up: 12 months
Outcome Measures	Average cost and overall costs post-joining, patient self-reported adherence
Baseline Characteristics		Office visit (n = 54)	Emergency room visit (n = 23)	Inpatient visits (n = 10)
	Pre-joining costs Average costs Overall costs	$47.70 $22,946.45	$1,378.33 $56,381.80	$16,002.16 $222,522.42
	Pre-joining average number of visits	10.22	1.87	1.60
Results	Endpoint	Office visit (n= 67)	Emergency room visit (n= 12)	Inpatient visits (n= 3)
	Post-joining costs Average costs Overall costs	$66.41 $34,722.91	$1,722.08 $32,167.63	$17,016.19 $55,911.58
	Post-joining average number of visits	7.07	1.33	1.33
	Office visit costs were found to increase by $11,776.41, but cost savings of $24,214.17 and $166,610.84 were realized for emergency room visits and inpatient visits. A substantial cost savings of $179,047.80 was found when the total costs for the employees, their spouses, and dependants were taken into account. Adherence was found to decrease marginally for the study population at six months but improved at 12 months. The overall improvement in adherence was found to be statistically significant (p= 0.003).
Adverse Events	N/A
Study Author Conclusions	This MTM program had numerous positive outcomes for both employers and employees. Employers realized overall cost savings of $179,047.80, while employees showed a significant increase in patient satisfaction and self-reported adherence with medication. The positive economic and humanistic results of this study provide supporting evidence for implementation of employer-sponsored, pharmacist-led MTM programs.
Critique	The study can be subject to selection bias since the participants were excluded if they were not related to medical insurance and prescription coverage of the City of Toledo. Recall bias is also likely due to the self-reported nature of outcomes that may underestimate the adherence.

References:
[1] Pinto SL, Kumar J, Partha G, et al. Improving the economic and humanistic outcomes for diabetic patients: making a case for employer-sponsored medication therapy management. Clinicoecon Outcomes Res. 2013;5:153-159. doi:10.2147/CEOR.S40735

The Evaluation of Comprehensive Medication Management for Chronic Diseases in Primary Care Clinics, A Texas Delivery System Reform Incentive Payment Program
Design	Retrospective, observational study N= 3,280
Objective	To evaluate the effectiveness of this Comprehensive Medication Management (CMM) program in decreasing drug therapy problems and related medical costs
Study Groups	Patients (N= 3,280)
Inclusion Criteria	Age > 18 years, taking 4 or more prescribed medications diagnosed with at least one of the chronic diseases: hypertension, congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes
Exclusion Criteria	N/A
Methods	Patient charts during the study period were reviewed by clinical pharmacists to manage polypharmacy patients. Pharmacist's recommendations could be 'accepted', 'partial', or 'declined'. The cost benefits were analyzed using local institutional data.
Duration	Study period: October 2015 to September 2016
Outcome Measures	Number of drug therapy problems, 'accepted' and 'partial' implementation rates, cost-savings based on potential services avoided
Baseline Characteristics		Patients (N= 3,280)
	Age, years 18 to 39 40 to 64 65 to 79 80+ years	211 (6.43%) 1,559 (47.53%) 1,161 (35.40%) 349 (10.64%)
	Women	2,022 (61.65%)
	White Black Other	1,961 (59.79%) 605 (18.45%) 714 (21.77%)
	Number of chronic diseases 1 2 3 4 5	1,704 (51.95%) 1,283 (39.12%) 253 (7.71%) 38 (1.16%) 2 (0.06%)
	Number of drug therapy problems 0 1 2 3	3,000 (91.46%) 260 (7.93%) 19 (0.58%) 1 (0.03%)
Results	Endpoint	Patients (N= 3,280)
	Number of drug therapy problems 'Accepted' implementation rates 'partial' implementation rates	301 151 (49.8%) 129 (42.8%)
		Estimated cost per event (2016 US dollars)	Total savings
	Estimated cost-savings based on potential services avoided Clinic outpatient visit Specialty visit Emergency room visit Hospital admission Reduce/Increase drug product	$206 $264 $1021 $17,263 Varied, calculated based on average wholesale price of drugs	$26,986 $2904 $67,386 $1,070,306 $18,028
Adverse Events	N/A
Study Author Conclusions	By reviewing electronic health records of 3,280 patients, the pharmacist identified 301 drug therapy problems and resolved 49.8% of these problems with collaboration from the patient’s primary care physician or care team. The most commonly identified drug problems were related to potentially adverse drug reactions or inappropriate drug dosage. The CMM program resulted in potential cost savings of $1,143,015.
Critique	This was one of the more recent data showing the interventions of a pharmacist in an outpatient setting. However, the study period ranged from October 2015 to September 2016, nearly 5 years ago which may not reflect the current economic climate of the COVID-19 pandemic.

References:
[1] [1] Chung TH, Hernandez RJ, Libaud-moal A, et al. The evaluation of comprehensive medication management for chronic diseases in primary care clinics, a Texas delivery system reform incentive payment program. BMC Health Serv Res. 2020;20(1):671.

Postdischarge pharmacist medication reconciliation: Impact on readmission rates and financial savings
Design	Retrospective, cohort, comparison and quality improvement analysis N= 494
Objective	To assess the impact of ambulatory clinical pharmacist medication therapy assessment and reconciliation for patients postdischarge in terms of hospital readmission rates, financial savings, and medication discrepancies
Study Groups	Medication review group (n= 243) Comparison group (n= 251)
Inclusion Criteria	All patients identified as high risk for readmission were followed by Group Health care management
Exclusion Criteria	Patients discharged to a location other than home or home with home health services
Methods	Patients with a higher risk of readmission who needed transition care management were identified by the hospital care team at a Group Health rapid process improvement workshop with our sources and references used. One to two days postdischarge nurses called the patients in the care management to inform them of the upcoming phone calls from the pharmacists for a more comprehensive medication review. Pharmacists would contact the patients 72 hours ppostdischargeo go over their medication lists, including medication omissions, therapeutic duplicates, dose changes, discontinued medications, and drug-drug interactions. All encounters were documented on the electronic medical records and the time spent for each case. The 14-day readmission data was used to calculate financial savings.
Duration	September 2009 to February 2010
Outcome Measures	Readmission rates, financial savings, and medication discrepancies
Baseline Characteristics		Medication review (n= 243)	Comparison (n= 251)	p-value
	Mean age, years	67	67	0.69
	Age ≥ 85 years	41 (16.9%)	42 (16.7%)	0.99
	Female	134 (55%)	128 (51%)	0.60
	Mean No. medical encounters Inpatient admits within 12 months of hospitalization ED visits within 12 months of hospitalization	4.4 1.5	5 1.5	0.99 0.99
	Medicare status at hospitalization	125 (51%)	146 (58%)	0.16
	Patients aged >65 years on HRME^*	21 (9%)	29 (12%)	0.36
	Primary care physician at time of hospitalization	213 (88%)	235 (94%)	0.03
	Number of medications Prescription Over-the-counter	7 2	7 2	0.33 0.87
	^*high-risk medication in the elderly Most frequent discharge diagnoses included chest pain, pneumonia, GI hemorrhage, syncope and collapse, general symptoms, atrial fibrillation, acute pancreatitis, congestive heart failure, abdominal pain, acute myocardial infarction. No significant p-values were noted between the two groups.
	Abbreviations used: ED, emergency department; GI, gastrointestinal; HRME, high-risk medication in the elderly9; PCP, primary care physician.
Results	Endpoint	Medication review (n= 243)	Comparison (n= 251)	p-value
	No. of readmitted patients 7-day 14-day 30-day	2 (0.8%) 11 (4.5%) 28 (11.5%)	11 (4.4%) 22 (8.8%) 34 (13.5%)	0.01 0.04 0.29
	Most frequent admission diagnoses Congestive heart failure	4	0	0.02
		Patients with ≥1 discrepancies	Total no. of discrepancies in medication review
	Medication discrepancies Discontinued medications Omissions Dose changes Therapeutic duplications Drug-drug interactions	48% 46% 44% 18% 8%	264 250 186 69 24
	Other frequent admission diagnoses included chest pain, GI hemorrhage, syncope and collapse, abdominal pain, chronic airway obstruction, intestinal obstruction, pancreatic cancer, pneumonia, and shortness of breath (p-values not significant). A labor cost of $45.22 per medication reconciliation translates to $4,522 for each 100 patients receiving medication reconciliation. The number needed to treat of 25 corresponds to four readmissions prevented per 100 patients. With the cost of readmission estimated at $10,000, this equals a gross savings of $40,000 per 100 medication reconciliation services. Subtracting the cost for pharmacist labor ($40,000 – $4,522) results in a net savings per 100 patients of $35,478.
Adverse Events	N/A
Study Author Conclusions	Most literature on medication reconciliation evaluates inpatient processes, whereas data on medication reconciliation popostdischargere limited. Our data support the hypothesis that medication assessment and reconciliation by pharmacists 3 to 7 days popostdischargean decrease readmissions and provide cost savings.
Critique	This retrospective cohort study has its inherent limitations in design. Researchers did not formally evaluate if the admissions or readmissions were medication-related. Overall, the data regarding pharmacist interventions in post-discharge medication management is promising.

References:
[1] [1] Kilcup M, Schultz D, Carlson J, Wilson B. Postdischarge pharmacist medication reconciliation: impact on readmission rates and financial savings. J Am Pharm Assoc (2003). 2013;53(1):78-84. doi:10.1331/JAPhA.2013.11250

Clinical and Economic Benefits of Pharmacist Involvement in a Community Hospital-Affiliated Patient-Centered Medical Home
Design	Single-center, retrospective, quality improvement study N= 63
Objective	To exhibit the clinical and economic benefit of pharmacist involvement in accountable care organization (ACOs) and patient-centered medical homes (PCMHs) as documented by clinical interventions (CIs) and drug cost reductions
Study Groups	Participants (N= 63)
Inclusion Criteria	Any adult patient with an eligible insurance plan who was let by a pharmacist with a documented clinical intervention
Exclusion Criteria	N/A
Methods	Documented cases of patient interventions by pharmacists were analyzed. Pharmacists were consulted by providers for patient medication management through follow-up MTMs. Any cost management CIs were defined as a direct cost savings from switching one medication to another.
Duration	Study period: October 2016 to March 2017
Outcome Measures	Documented clinical interventions and recommendations to a cheaper therapy with calculated cost-savings
Baseline Characteristics		Participants (N= 63)
	Age, years	68
	Women	50 (79%)
Results	Endpoint	Participants (N= 63)
	Number of documented CIs	283
	MTM interventions cost management interventions patient/provider education intervention Transition of care medication reconciliations collaborative drug therapy management interventions	94 (33.2%) 88 (31.1%) 37 (13.1%) 36 (12.7%) 28 (9.9%)
	Recommendations to switch to a less expensive alternative Extrapolated cost savings	16 $118,409
Adverse Events	N/A
Study Author Conclusions	Clinical benefit of pharmacy services was demonstrated through documented CIs. Pharmacists can have a dramatic and quantitative effect on reducing drug costs by recommending less expensive generic or therapeutic alternatives. Documenting CIs allows pharmacists to provide valuable evidence of avoided drug misadventures and identification of medication discrepancies. Such evidence supports an elevated quality of care.
Critique	Although a small patient population, this reflects a recent attempt at measuring cost management in an outpatient setting.

References:
[1] [1] Tate ML, Hopper S, Bergeron SP. Clinical and economic benefits of pharmacist involvement in a community hospital-affiliated patient-centered medical home. J Manag Care Spec Pharm. 2018;24(2):160-164.

Return-On-Investment for Billable Pharmacist-Provided Services in the Primary Care Setting
Design	Prospective study N= 39 practice sites
Objective	To describe pharmacist-delivered billable and non-billable patient-centered care services and assess the impact of various billing methods on an ambulatory care pharmacy department’s return-on-investment (ROI) for billable services
Methods	Data sources included electronic health records, pharmacist flowsheets, and internal financial reports. Potentially billable services comprised hospital-based fee codes (G0463) and/or chronic care management codes. Total expenses, including benefits, for a full-time equivalent pharmacist was calculated as $170,898. The number of pharmacist hours devoted to billable services was calculated by multiplying the number of annual encounters by time spent for encounters.
Duration	September 1, 2016, to August 31, 2017
Outcome Measures	ROI for potentially billable services
Results	Summary of Return-On-Investment (ROI) for Billed Services and Billed Services Plus Missed Billing Opportunities
	----	Total hours (FTE)	Total revenue (cost of pharmacist services)	ROI^a on billed services	Billed services plus missed billing opportunities (cost of pharmacist services)	ROI^a on billed services plus missed billing opportunities
	Billed	948.3 hours	$173,638.66	-	-	-
	Services	(0.46 FTE)	($78,613.08)	1.2:1	-	-
	Missing billing	158.1 hours	$68,268.37	-	$241,907.03	-
	Opportunities	(0.08 FTE)	($13,671.84)	-	($92,284.92)	1.6:1
	948.3 total hours for all encounters = 0.46 FTE
	FTE: Full-time equivalent, 2,080 Hours ^a1.0 FTE pharmacist salary and benefits for ROI calculation was estimated to be $170,898
	Type and Total Avenue of Encounters From September 2016 to August 2017
	Encounter type			Total revenue
	Annual Wellness Visits^b			$138,595.21
	Immunizations			$20,550.46
	Screenings (alcohol, smoking cessation, and depression)			$8,625.27
	Transitions of Care^c			$3,600.00
	Comprehensive Medication Review			$750.00
	Total			$173,638.66
	^bPharmacists received an incentive payment from a commercial payer for completing initial annual wellness visits. ^cPharmacists were part of the team that provided transitions of care services. The pharmacist’s role was to perform a comprehensive medication review (CMR), and $50 of the payment was allocated for provision of the CMR during a transition of care encounter.
Study Author Conclusions	Study findings indicate that the integration of billable methods, such as incident to and Medicare Annual Wellness Visits (AWVs), to finance pharmacist-provided clinical services in the primary care setting resulted in a positive ROI for billable services. However, the majority of the time was spent performing non-billable services, which did not result in an overall positive ROI. To realize a sustainable business model, pharmacists should be performing a high volume of billable services. Billing G0463 (encounters eligible for the hospital-based facility) and chronic care management (CCM) codes, when applicable, are revenue sources that have the potential to increase ROI yet may be underutilized. Pharmacists should work with their organizational leadership to maximize billing opportunities in the outpatient setting.
Critique	Only 17% of clinical time was spent addressing billable services, which did not translate into a positive ROI. Implementing a minimum number of daily visits (similar to physician models) may increase efficiency and ensure proper revenue. Pharmacists may also bring value to a team via non-billable services that are still important, such as drug information responses, work on committees, and development of protocols.

References:
[1] [1] Tran T, Moczygemba LR, Musselman KT. Return-On-Investment for Billable Pharmacist-Provided Services in the Primary Care Setting [published online ahead of print, 2021 May 26]. J Pharm Pract. 2021;8971900211013194. doi:10.1177/08971900211013194

Billing for pharmacists’ cognitive services in physicians’ offices: Multiple methods of reimbursement
Design	Retrospective, observational analysis N= 6,930
Objective	To (1) evaluate charges and reimbursement for pharmacist services in an outpatient family health center recognized as a patient-centered medical home (PCMH) and (2) determine the number of patients that must be managed by a pharmacist to cover the cost of salary and fringe benefits
Methods	This study was a retrospective analysis of financial data during a 4-year period (2006–10) in three ambulatory care practices with well-established clinical pharmacy services in North Carolina. Data were collected from monthly and annual internal financial reports and an electronic medical record and included annual charges and collections, clinic capacity, number of patients seen (monthly and annually), and patient no-show rates. Four different clinics were managed by the pharmacists, including anticoagulation, pharmacotherapy, osteoporosis, and wellness clinics. “Incident to” level 1 billing was used for the anticoagulation and pharmacotherapy clinics, whereas level 4 codes were used for the osteoporosis clinic. The wellness clinic utilized a negotiated fee-for-service model.
Duration	2006 to 2010
Outcome Measures	Encounters, total charges, total reimbursement
Baseline Characteristics	Problems	Time involved, minutes	Level of visit	North Carolina Medicare reimbursement
	Minimal	5	“Level 1” or nurse visit	$19.06
	Self-limited to minor	10	“Level 2” visit	$40.04
	Low to moderate severity	15	“Level 3” visit	$66.83
	Moderate to high severity	25	“Level 4” visit	$99.21
	Moderate to high severity	40	“Level 5” visit- typically involves full examination	$133.56
Results	Fiscal year	Encounters	Charges using level 1 billing	Reimbursement (reimbursement rate)
	2007-08	1,142	$36,036	$24,201 (67%)
	2008-09	1,515	$41,131	Not reported (N/A)
	2009-10	2,025	$70,925	$20,387 (29%)
	2010-11	1,953	$57,195	$25,432 (45%)
	Mean	1,658	$51,322	$23,340 (47%)
	The mean annual charges were $65,022, and the mean reimbursement rate was 47%. The mean charge and collection per encounter were $41 and $19, respectively. Eleven encounters per day were necessary to generate enough charges to pay for the cost of the pharmacist. Considering actual reimbursement rates, the number of patient encounters necessary increased to 24 per day.
Study Author Conclusions	Unique opportunities for pharmacists to provide direct patient care in the ambulatory setting continue to develop. The use of a combination of billing methods resulted in sustainable reimbursement. The ability to bill at the level of service provided instead of a level 1 visit would decrease the number of patients needed to pay for a pharmacist.
Critique	This study used real-world data, but assumptions had to be made to allow for predictions.

References:
[1] [1] Scott MA, Hitch WJ, Wilson CG, Lugo AM. Billing for pharmacists' cognitive services in physicians' offices: multiple methods of reimbursement. J Am Pharm Assoc (2003). 2012;52(2):175-180. doi:10.1331/JAPhA.2012.11218

Outcomes of annual wellness visits provided by pharmacists in an accountable care organization associated with a federally qualified health center
Design	Retrospective, single-center, chart review N= 300
Objective	To evaluate the financial outcomes of annual wellness visits (AWVs) conducted by clinical pharmacists working as part of an accountable care organization (ACO) in a federally qualified health center in Arizona
Study Groups	All patients (N= 300)
Inclusion Criteria	Patients met criteria for Medicare AWV and were seen by clinical pharmacists
Exclusion Criteria	Patients seen by other healthcare providers or for whom charts were not available
Methods	Data collected from patient charts included revenues collected from AWV and preventive screenings.
Duration	October 2013 to December 2013
Outcome Measures	Revenue from AWVs and services provided
Baseline Characteristics		All patients (N= 300)
	Age, years	64.4 ± 4.6
	Female	172 (57%)
	Body-mass index, kg/m²	29.5 ± 2.4
	Chronic diseases Hypertension Dyslipidemia Diabetes mellitus Chronic kidney disease Depression	190 (63%) 150 (50%) 148 (49%) 89 (30%) 48 (16%)
Results	Endpoint	Total charges	Contract-allowed amount	Total revenue
	Month and year October 2013 November 2013 December 2013 Total	$19,178 $23,731 $19,820 $62,729	$8,626 $12,038 $9,994 $30,659	$6,937 $9,151 $6,252 $22,340
	Service	Number of orders	Unit price	Total revenue
	Mammogram Laboratory testing Hemoglobin A_1c Lipid panel Other Vaccination Pneumococcal Tetanus, diphtheria, and pertussis Influenza Total	40 - 100 52 249 - 37 40 72 -	$361.00 - $48.50 $68.50 Varied - $64.00 $44.00 $30 -	$14,440.00 - $4,850.00 $3,562.00 $7,239.00 - $2,368.00 $1,760.00 $2,160.00 $36,379.00
Adverse Events	N/A
Study Author Conclusions	Recommendations made by pharmacists during AWVs in an ACO associated with a federally qualified health center had a high acceptance rate and generated substantial revenue.
Critique	The short study duration used in this analysis limits the conclusions regarding long-term revenue generated. According to the authors, data on net financial benefit could not be calculated and included after calculating all other expenses

References:
[1] [1] Alhossan A, Kennedy A, Leal S. Outcomes of annual wellness visits provided by pharmacists in an accountable care organization associated with a federally qualified health center. Am J Health Syst Pharm. 2016;73(4):225-228. doi:10.2146/ajhp150343

Outcomes of systematic anticoagulation management in pharmacist and nurse-specialized clinics
Design	Retrospective, observational, cohort study N= 200
Objective	To compare the quality of anticoagulation-related outcomes via two models of care, pharmacist-managed anticoagulation clinic (PMAC) and nurse-managed anticoagulation clinic (NMAC).
Study Groups	PMAC (n= 100) NMAC (n= 100)
Inclusion Criteria	Age > 18 years, treated with warfarin at UI health for a minimum of 1 months.
Exclusion Criteria	N/A
Methods	Patient data from the outpatient pharmacist-run, clinic where warfarin patients received management therapy was collected. This data was compared with the NAMC, who also received warfarin patients from the same location. Based on the institutional collaborative practice agreement, pharmacists and nurses independently dosed and managed warfarin.
Duration	15-month period
Outcome Measures	Secondary outcome: Warfarin-related hospitalizations and emergency department (ED) visits.
Baseline Characteristics		PMAC (n= 100)	NMAC (n= 100)
	Age, years	58.7 ± 15.5	64.2 ± 13.2
	Female	65%	52%
	White African American Hispanic Other	14% 58% 25% 3%	26% 41% 29% 4%
	Indication for warfarin Venous thromboembolism Peripheral vascular disease stroke Atrial fibrillation Mechanical valve replacement (MVR) Other	66% 12% 11% 9% 2% 0	3% 1% 2% 53% 39% 2%
	Goal INR range 2-3 2.5-3.5	84% 11%	63% 32%
	Greater than 3 missed monitor meeting	78%	33%
	Include relevant baseline characteristics that will provide a general (big picture) view of the patients in the study.
Results	Endpoint	NMAC (n= 100)	PMAC (n= 100)
	Hospitalization/ED visits: Hemorrhages Charge due to hemorrhage	14 $773,522	13 $718,270
	Hospitalization/ED visits: Embolisms Charge due to embolism	1 $59,100	2 $188,199
	Hospitalization/ED visits: Non-therapeutic INR Charge due to non-therapeutic INR	22 $553,445	1 $24,247
	Total cost Cost avoided by PMAC	$1,366,066 $505,349	$860,717 -
Adverse Events	N/A
Study Author Conclusions	The quality of warfarin anticoagulation did not differ between pharmacist and nurse-managed models of anticoagulation care; however, PMACs decreased the odds of warfarin-related hospitalizations/ED visits and their associated costs.
Critique	Aside from the retrospective nature of the study introducing bias, baseline characteristics were significantly different between groups. The authors did not attempt to correct for differences in hospitalization and ED visits. Lastly, the study focuses on warfarin anticoagulation.

References:
[1] [1] Manzoor BS, Bauman J, Shapiro NL, Stamos T, Galanter W, Nutescu EA. Outcomes of systematic anticoagulation management in pharmacist and nurse specialized clinics. J Am Coll Clin Pharm. 2018;1(2):68-73.

Cost and Effectiveness of Pharmacist-Led Group Medical Visits for Type-2 Diabetes: A Multicenter Randomized Controlled Trial
Design	Multisite, randomized, controlled, parallel design trial N= 250
Objective	To determine the impact of a pharmacist-led group medical visit intervention added to standard care compared to standard care alone for patients with Type-2 DM on glycemia, blood pressure, lipids, health status, and healthcare system costs
Study Groups	Pharmacist-led group visit (n= 117) Standard care (n= 113)
Inclusion Criteria	All patients over the age of 18 with documented Type-2 DM in the medical record, a last recorded hemoglobin A1c of >7.0%, and at least one of the following: 1. Smoker (any cigarette smoking < 30 days) 2. An LDL >100 mg/dl in the last blood draw 3. A blood pressure >130/80 mm Hg documented on at least two occasions within the last 6 months
Exclusion Criteria	Pregnancy, psychiatric instability, NYHA class 3 or 4 heart failure, liver cirrhosis, end-stage renal disease, dialysis, end-stage cancer, or organic brain injury
Methods	Patients were randomly assigned to receive either a clinical pharmacist-led group medical visits in addition to standard primary care or receive standard primary care alone. The clinical pharmacist-led group medical visit consisted of American Diabetes Association Standards of Diabetes Self-Management education on diabetes self-care during the first hour, followed by behavioral counseling and comprehensive medication management for hyperglycemia, hypoglycemia, hypertension, and dyslipidemia during the second hour. The clinical pharmacists who delivered these group medical visits were required to have at least one year of postgraduate residency training or equivalent in outpatient clinical care. Each visit consisted of 4–6 participants and lasted around 120 minutes. Group medical visits were held once weekly for over 4 weeks, followed by 4 booster sessions held once every 3 months. The standard care group regularly visited primary care and specialty care providers. The patients received an average of 4 visits per year with their primary care provider, with additional visits scheduled on an as-needed basis determined by the physician.
Duration	13 months
Outcome Measures	The mean change in the UKPDS risk score, which consists of change from baseline in A1c, systolic blood pressure, and LDL-cholesterol Change in cost
Baseline Characteristics		Pharmacist-led Group Visit (n= 117)	Standard Care (n= 133)
	Age, years	65.8 ± 8.7	65 ± 9.8
	Male	95.7%	96.2%
	Duration of diabetes, years	13.5 ± 9.4	12.4 ± 9.9
	Hypertension	92.3%	85%
	Hyperlipidemia	87.2%	91%
	Coronary Heart Disease	39.3%	43.6%
	Stroke	10.3%	3.8%
	Congestive Heart Failure	10.3%	9.8%
	Chronic Obstructive Pulmonary Disease	11.1%	15.8%
	Active smoker	21.4%	27.1%
	Systolic blood pressure, mmHg	136.5 ± 19.0	136.2 ± 17.4
	Diastolic blood pressure, mmHg	75.1 ± 11.4	75.3 ± 10.5
	Total Cholesterol, mg/dL	155.2 ± 33.5	165.3 ± 39.7
	HDL Cholesterol, mg/dL	37.8 ± 10.9	38.1 ± 9.5
	LDL Cholesterol, mg/dL	87.6 ± 29.8	93.7 ± 33.7
	Hemoglobin A1c	8.2% ± 1.5%	8.2% ± 1.3%
Results	Endpoint	Pharmacist-led Group Visit (n= 117)	Standard Care (n= 133)	p-value
	Mean change in UKPDS risk score	-0.02 ± 0.09	-0.04 ±0.09	0.45
	Mean change in hemoglobin A1c	-0.27 ± 1.25%	-0.14 ± 1.23%	0.30
	Mean change in systolic blood pressure, mmHg	-6.9 ±19.7	-8.9 ± 17.4	0.12
	Mean change in low-density lipoprotein, mg/dL	-5.4 ± 30.1	-14.2 ± 30.0	0.12
	Mean change in cost 13 months after Study period minus 13 months of Study period, $	-1575 ± 30774	2360 ± 23708	< 0.01
Study Author Conclusions	The addition of pharmacist-led group medical visits in T2DM achieved similar improvements in cardiovascular risk factors to usual care, while outpatient care costs decreased. Furthermore, thirteen months after the completion of the intervention, healthcare costs in group medical visits decreased to below baseline levels compared to the steady rise in cost of usual care. Future studies should be conducted in the non-VHA setting to assess the generalizability of the results.
Critique	Only about 40% of individuals contacted agreed to participate in the study. This suggests that group visits may not fit all patients with type 2 diabetes. Only patients who sought care in VHA hospitals were included in the study. as a result, the patients in this selection are primarily male.

References:
[1] Wu WC, Taveira TH, Jeffery S, et al. Costs and effectiveness of pharmacist-led group medical visits for type-2 diabetes: A multi-center randomized controlled trial. PLoS One. 2018;13(4):e0195898. Published 2018 Apr 19. doi:10.1371/journal.pone.0195898

Economic Impact of Ambulatory Clinical Pharmacists in an Advanced Heart Failure Clinic
Design	Prospective, observational, single-center study N= 2,361 interventions
Objective	To evaluate the economic impact of heart failure (HF) clinical pharmacist interventions in an advanced HF clinic using a cost-benefit analysis
Study Groups	All interventions (n= 2,361)
Inclusion Criteria	Advanced HF patients at West Virginia University Medicine Heart and Vascular Institute's Advanced HF and Pulmonary Hypertension services institute who received care from the HF ambulatory clinical pharmacists
Exclusion Criteria	Not specified
Methods	The economic impact of the interventions was estimated based on the indirect cost savings with pharmacist interventions and direct cost savings recommendations. A cost-benefit analysis was performed to assess the cost of delivering the interventions compared with the benefits generated by clinical pharmacists. Benefits included cost avoidance from pharmacist interventions and any additional direct cost savings. the cost of interventions included direct personnel costs, fringe benefits, and additional equipment costs. Results were reported as a benefit-cost ratio and net benefits (cost avoidances from interventions plus additional direct cost savings divided by total costs) and net benefits (total cost savings – total costs). A sensitivity analysis was performed to account for variability in study estimates. The intervention list included the addition of medication, adverse drug event (ADE) detection, medication change, discontinuation of a medication, dosage form change, dose change, drug information or therapy consultation from providers, medication reconciliation, patient education, lab/referral to other services or Quitline, medication adherence check, and amiodarone ADE monitoring. Other cost-saving interventions included formulary exceptions, therapeutic alternatives, and tier exceptions.
Duration	April 1 to September 30, 2021 (six months)
Outcome Measures	Cost-benefit analysis
Results	Summary of pharmacist cost-saving intervention cost-benefit analysis
	Endpoint	Original analysis, $	Sensitivity analysis, $ (±20% of personnel cost)
	Direct cost saving	32,875.3	32,875.3
	Indirect cost saving	123,680.4	123,680.4
	Total cost saving (direct and indirect cost savings)	156,555.7	156,555.7
	Direct personnel cost	100,222.5	80,178-120,267
	Additional equipment cost (blood pressure off)	780	780
	Overheads (office supplies, electricity, office space)	Minimal	Minimal
	Total cost	101,002.5	80,958-121,047
	Net benefits	55,553.2	35,508.7-75,597.7
	Benefit-cost ratio	1.55	1.29-1.93
	Most common intervention types Medication reconciliation Dose change Addition of medication	28.7% 20.8% 12.3%
	Most common intervened class Anticoagulant Sodium-glucose cotransporter-2 (SGLT2) inhibitor Angiotensin receptor neprilysin inhibitor (ARNI)	21.2% 12.3% 9.2%
Study Author Conclusions	Cardiology clinical pharmacists demonstrated their roles in optimizing HF pharmacotherapy and generating economic savings in an advanced HF clinic. The addition of cardiology clinical pharmacists to the advanced HF service may be financially justified and cost-beneficial.
Critique	Since the study was conducted from April to September over a period of six months, the reported annual savings may not apply to the savings due to seasonal variations in clinical interventions. Furthermore, due to the lack of a control group, no comparison was made in the change in cost savings before and after pharmacists' implementation in the HF clinic. This study is further limited by its single-center design, and the findings may not be applicable to other institutions with different work circumstances. Lastly, other clinical outcomes, such as hospitalization rate for HF or mortality rates, were not evaluated.

References:
[1] [1] Kido K, Colvin BM, Broscious R, Bongiorni S, Sokos G, Kamal KM. Economic Impact of Ambulatory Clinical Pharmacists in an Advanced Heart Failure Clinic [published online ahead of print, 2022 Feb 15]. Ann Pharmacother. 2022;10600280221075755. doi:10.1177/10600280221075755

Economic impact of pharmacist interventions in pediatric ambulatory care clinics
Design	Single-center, retrospective chart review N= 212 interventions
Objective	To determine the total cost avoidance of pharmacist interventions associated with the prevention or management of adverse drug events (ADEs) in pediatric ambulatory care clinics
Study Groups	ADE intervention (N= 212)
Inclusion Criteria	Ambulatory care pharmacist interventions of patients aged 21 years or younger
Exclusion Criteria	Interventions correlated to medication incompatibilities with medical devices (e.g., inappropriate medication administration through enteral tubes), interventions related to treatment recommendations (e.g., increasing doses based on the patient’s weight), potential drug interactions if there were no medication changes or laboratory test orders necessary at the time of intervention documentation
Methods	Pharmacist interventions from pediatric ambulatory care clinics were collected from an electronic health record. These interventions were categorized into 1 of 4 categories: Drug interaction, drug not indicated, prevent or manage ADE, or prevent or manage drug allergy.
Duration	Between October 1, 2019, and January 31, 2020
Outcome Measures	Cost avoidance
Baseline Characteristics		ADE intervention (N= 212)
	Age, years	12 (interquartile range [IQR] 7-16)
	Male	115 (54.3%)
	White	129 (60.9%)
	Insurance type Commercial Medicaid Uninsured	80 (37.7%) 128 (60.4%) 4 (1.9%)
	Clinic Adolescent medicine Complex healthcare Endocrinology Gastroenterology Immunodeficiency Internal medicine Neurology Pediatric primary care Pulmonology Rheumatology	6 (2.8%) 62 (29.3%) 0 21 (9.9%) 3 (1.4%) 17 (8%) 9 (4.3%) 29 (13.7%) 34 (16%) 31 (14.6%)
	ADE subtype interventions Drug interaction Drug not indicated Prevent or manage ADE Prevent or manage drug allergy	25 (11.8%) 37 (17.5%) 147 (69.3%) 3 (1.4%)
Results	ADE intervention type	Nesbit score	Number of interventions ^a	Cost avoidance ^a, $	Total cost avoidance, $
	Drug interaction	0.01 0.1 0.4 0.6	1 0 16 8	2 0 40,020 88,261	128,283
	Drug not indicated	0.01 0.1 0.4 0.6	9 4 12 12	491 21 19,723 492	20,727
	Prevent or manage ADE	0.01 0.1 0.4 0.6	39 21 58 29	1,964 5,033 3,198 147,798	157,993
	Prevent or manage drug allergy	0.01 0.1 0.4 0.6	1 0 1 1	2 0 82 123	207
					307,210
	Total cost avoidance by the clinic
	Clinic	Number of intervention	Median age, years	Cost avoidance, $
	Adolescent medicine Complex healthcare Endocrinology Gastroenterology Immunodeficiency Internal medicine Neurology Pediatric primary care Pulmonology Rheumatology	6 62 0 21 3 17 9 29 34 31	17 8 - 15 17 10 8 7 16 14	23 89,633 0 59,380 246 1,404 332 6,326 2,926 146,939
	^aIncludes all levels of care (self-care, ambulatory care, and emergency department visits or hospitalizations).
Adverse Events	N/A
Study Author Conclusions	Pediatric ambulatory care pharmacists optimize healthcare cost savings through the prevention and management of ADEs as integrated members of the healthcare team.
Critique	The authors claim that the present study was the first to determine the impact of pharmacist interventions associated with the prevention or management of ADEs in the pediatric ambulatory care setting. Yet, the presented data only represents a single pediatric institution's retrospective experience estimated over a 4-month study period.

References:
[1] [1] Yung E, McNicol M, Lewis D, et al. Economic impact of pharmacist interventions in pediatric ambulatory care clinics. J Am Pharm Assoc (2003). 2021;61(2):198-205.e1. doi:10.1016/j.japh.2020.11.009

Development and economic evaluation of a pharmacist provided chronic care management service in an ambulatory care geriatrics clinic
Design	Single-center, prospective study N= 36
Objective	To describe the implementation and delivery of a pharmacist-led chronic care management (CCM) service in a geriatric primary care clinic
Study Groups	All patients (n= 36)
Inclusion Criteria	Patients aged ≥ 65 years who were affiliated with the Hospital Senior Clinic and qualified for CCM services; ≥ 2 chronic conditions; no transition of care (TOC) service billable in the same calendar month; participating insurance (Medicare, Aetna, Humana, Cigna [based on member plan]); accomplished one of the following: 1) annual wellness visit, 2) initial preventative physical exam, 3) comprehensive evaluation and management visit Chronic condition: a condition expected to last ≥ 12 months or until death of patient; and a condition that places the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
Exclusion Criteria	Dual Medicaid/Medicare patients
Methods	Eligible patients, whether identified by the physician in charge with medication need or prospectively targeted by clinical pharmacists, such as based on an elevated (HbA1c) value ≥ 8.5%, were followed up by clinical pharmacists regarding the details of CCM. The initial encounter would typically include a comprehensive medication review, and pharmacists would discuss the recommendations with the providers. Followed by the initial encounter, the pharmacists typically focused on managing one or two chronic conditions each month with regular telephone follow-ups with the patients to obtain necessary objective/subjective information for therapeutic plans. All clinical encounters were documented in the clinical notes via the electronic health record (EHR) for the physician's approval or modifications.
Duration	March 1 through December 31, 2016
Outcome Measures	Time spent during the patient's EHR review, during the phone call, and required for clinical documentation; reimbursement data
Baseline Characteristics		All patients (n= 36)
	Mean age, years	80 ± 6
	Female	22 (61.1%)
	White	25 (69%)
	Mean no. medications per patient (range)	14 (7 to 24)
	Mean no. chronic conditions per patient (range)	5.8 (3 to 9)
	Targeted conditions Diabetes mellitus Hypertension Insomnia Medication review Pain Other	14 (38.9%) 4 (11.1%) 2 (5.6%) 9 (25%) 2 (5.6%) 5 (13.9%)
Results	Chronic Care Management Billing and Reimbursement, by Month
	Month	No. Patient Evaluated	Total Care Time, min	Mean Time Spent per Patient, min	No. Patients Reimbursed	Mean Amount Reimbursed per Patient, $
	March	6	169	28	6	28.05
	April	6	242	40	4	26.88
	May	5	156	31	4	46.88
	June	11	517	47	11	26.03
	July	7	321	46	7	26.20
	August	9	409	45	8	36.21
	September	12	629	52	12	26.33
	October	12	567	47	12	32.66
	November	15	849	57	15	31.51
	December	12^a	727	61	11	25.99
	Mean over 10 month	9.2	458.6	45.4	9	30.83
	^aOne patient was not billed/reimbursed due to an active transitional care management episode.
Adverse Events	N/A
Study Author Conclusions	Medicare patients were successfully enrolled in a CCM service in a geriatrics primary care clinic led by clinical pharmacists and medical providers. The CCM services were more time-consuming than the allotted 20 minutes per patient per month with the CCM Current Procedural Terminology code used during this study.
Critique	One of the limitations of evaluating the implementation of the CCM is that the clinical pharmacists typically have other responsibilities, including transitions-of-care comprehensive medication reviews, provider drug information questions, and patient education visits. Therefore, the total reimbursement by solely focusing on the CCM service may be potentially underestimated.

References:
[1] [1] Fixen DR, Linnebur SA, Parnes BL, Vejar MV, Vande Griend JP. Development and economic evaluation of a pharmacist-provided chronic care management service in an ambulatory care geriatrics clinic. Am J Health Syst Pharm. 2018;75(22):1805-1811. doi:10.2146/ajhp170723

Description and financial impact of ambulatory care pharmacy team interventions within an underserved patient population
Design	Retrospective, single-center, cohort study N= 1,334 interventions (N= 649 patients)
Objective	Primary: to characterize and quantify the types of interventions involving under-served patients made by an ambulatory care pharmacy team (ACPT) Secondary: to evaluate and quantify the cost avoidance from the interventions by the ACPT in an ambulatory care clinic and create a cost for specific interventions using the health system’s intervention documentation system
Study Groups	All interventions (N= 1,334)
Inclusion Criteria	Aged ≥18 years; had an appointment at the ambulatory care clinic; received a pharmacy consult
Exclusion Criteria	Not specified
Methods	Eligible patients received a pharmacy consult at a single center in Atlanta, Georgia, serving primarily indigent patients with chronic health conditions living in the underserved area. At the time of this study, the ACPT consisted of an ambulatory care pharmacist, pharmacy residents, and pharmacy students. The specific intervention, the number of specific interventions, the dollar amount of the financial impact per intervention, and the total amount of financial impact with the intervention were collected from the chart review. The interventions fell into 4 major categories, including patient counseling, drug utilization review (DUR), medication therapy management (MTM), and drug information (DI).
Duration	July 1, 2018, through June 30, 2020
Outcome Measures	Cost avoidance, economic impact
Baseline Characteristics		All patients (N= 649)
	Mean age, years	51
	Male	50%
	African American	70%
	Interventions (N= 1,334) Counseling DUR MTM DI	251 (18.8%) 342 (25.6%) 630 (47.2%) 111 (8.4%)
Results	Endpoint	Economic impact	Cost avoidance
	All interventions (N= 1,334) Counseling DUR MTM DI	$40,020 $7,523.76 $10,245.12 $18,889.44 $3,361.68	$477,065 $89,688.22 $122,128.64 $225,174.68 $40,073.46
	The economic impact per intervention was approximately $30. The average cost avoidance was estimated to be $357.62 per intervention, with a total economic impact of $40,020 and cost avoidance of $477,065 for the study period.
Study Author Conclusions	Pharmacist interventions resulted in a significant amount of economic impact and cost avoidance for the health system. Using the data from the study, we created a cost estimate to indicate the value of each ambulatory care intervention by using the health system’s intervention documentation system.
Critique	Aside from limitations inherent to the retrospective nature, the results lacked a follow-up period after each intervention. Moreover, cost avoidance is an estimated amount, and there was no verifiable dollar amount associated with each intervention.

References:
[1] [1] Hasham S, Moye-Dickerson P, Thurston MM. Description and financial impact of ambulatory care pharmacy team interventions within an underserved patient population. Am J Health Syst Pharm. 2023;80(Supplement_1):S42-S48. doi:10.1093/ajhp/zxac342

The impact of pharmacist practice of medication therapy management in ambulatory care: an experience from a comprehensive Chinese hospital
Design	Retrospective study conducted in a university-affiliated, tertiary comprehensive hospital in Beijing, China N= 81
Objective	To assess the beneficial effect of pharmacist-led MTMs on patients and discuss the current status and challenges of pharmacist-led MTMs in China
Study Groups	All patients (n= 81)
Inclusion Criteria	Patients who received at least one MTMs and with complete medical records and pharmaceutical documents from May 2019 to February 2020
Exclusion Criteria	Patients with incomplete medical records and pharmaceutical documents
Methods	Pharmacists provided pharmaceutical care according to MTMs standards, identified medication-related problems (MRPs), and developed medication-related action plans (MAPs). MRPs, pharmaceutical interventions, and resolving recommendations were documented. Cost of treatment drugs that patients can reduce was calculated
Duration	May 2019 to February 2020
Outcome Measures	Primary: Identification of MRPs and development of MAPs Secondary: Cost-saving per patient
Baseline Characteristics		All patients (n= 81)
	Age < 40	2 (2.47%)
	Age 40-64	21 (25.93%)
	Age 65-79	34 (41.98%)
	Age ≥ 80	24 (29.63%)
	Mean age	71.05 ± 13.01
	Male	33 (40.74%)
	Female	48 (59.26%)
	Number of comorbidities ≥ 5	55 (67.90%)
	Number of combined drugs 5-9	36 (44.44%)
	Number of combined drugs ≥ 10	31 (38.27%)
Results		Result
	Patients with MRPs	71 (87.65%)
	Total MRPs identified	181
	Average MRPs per patient	2.55
	Cost-saving per patient per month	$43.2
Adverse Events	Not applicable
Study Author Conclusions	By participating in the MTMs of outpatients, pharmacists could identify more MRPs and develop personalized MAPs timely for patients, promoting rational drug use and reducing medical expenses.
Critique	The study provides valuable insights into the implementation of MTMs in China, highlighting the role of pharmacists in identifying MRPs and reducing costs. However, it is limited by its single-center design, retrospective nature, and lack of a control group, which may affect the generalizability of the findings.

References:
[1] [1] Meng Q, Sun L, Ma Y, et al. The impact of pharmacist practice of medication therapy management in ambulatory care: an experience from a comprehensive Chinese hospital. BMC Health Serv Res. 2023;23(1):176. Published 2023 Feb 21. doi:10.1186/s12913-023-09164-6

Medication Therapy Management in the Primary Care Setting: A Pharmacist-Based Pay-for-Performance Project
Design	Pay-for-Performance (PFP) project initiated by a private insurer for clinic-based pharmacists in Iowa and South Dakota N= 827
Objective	To evaluate the effect of medication therapy management on chronic disease management and generic drug prescribing in the clinic setting
Study Groups	All patients (n= 827)
Inclusion Criteria	Patients with at least 1 of 4 disease states (diabetes mellitus, hyperlipidemia, hypertension, and asthma) assigned to pharmacists
Exclusion Criteria	Not specified
Methods	Pharmacists were assigned approximately 300 patients each and expected to complete 2 medication reviews per patient. The primary outcome was the frequency of patients achieving goal levels for diabetes, hypertension, hyperlipidemia, and asthma. Generic prescribing rates were evaluated for specific drug classes. Data were collected from 3 clinics using the same electronic health record system.
Duration	January 1, 2009, to February 28, 2010
Outcome Measures	Primary: Frequency of patients achieving goal levels for diabetes, hypertension, hyperlipidemia, and asthma Secondary: Generic prescribing rates for antihypertensives, cholesterol-lowering agents, proton pump inhibitors, and antidepressants
Baseline Characteristics		All patients (n= 827)
	Mean age, years	53.2 (range 3-91)
Results		PharmD Clinics, Attained/All (%)	All Clinics, Attained/All (%)	p-Value
	Diabetes - Hb A1c <8.0%	101/131 (77.1)	9101/12 593 (72.3)	0.258
	Hypertension - BP <140/90 mm Hg	368/427 (86.2)	38 474/49 881 (77.1)	<0.001
	Hypercholesterolemia - LDL <130 mg/dL	241/299 (80.6)	Not reported	--
	Asthma - Controller medication	27/27 (100)	2131/2156 (98.8)	0.546
Adverse Events	Not specified
Study Author Conclusions	A high percentage of patients achieved goal levels at clinics with clinical pharmacist services. A multidisciplinary approach to patient care may improve disease state management and medication cost savings.
Critique	The study demonstrated improved clinical outcomes with pharmacist involvement, but was limited by its focus on only 3 clinics and the short duration of the project. The lack of a control group and potential selection bias due to the inclusion of clinics with established pharmacist services may limit the generalizability of the findings.

References:
[1] [1] Koenigsfeld CF, Horning KK, Logemann CD, Schmidt GA. Medication therapy management in the primary care setting: a pharmacist-based pay-for-performance project. J Pharm Pract. 2012;25(1):89-95. doi:10.1177/0897190011416671

Medication therapy disease management: Geisinger’s approach to population health management
Design	Retrospective analysis of EHR and administrative claims data N= 15,125 (AF patients), N= 1,728 (MS patients)
Objective	To describe pharmacists’ involvement in a population health initiative focused on chronic disease management and to demonstrate the MTDM program’s impact on patient outcomes
Study Groups	AF patients: MTDM-only (n= 7,309) MTDM/GHP (n= 3,610) GHP-only (n= 4,206) MS patients: MTDM-only (n= 744) MTDM/GHP (n= 259) GHP-only (n= 725)
Inclusion Criteria	Patients with a diagnosis of AF or MS identified on a patient problem list or during at least 2 patient encounters, prescribed warfarin (AF) or having at least 1 clinic encounter (MS), and at least 18 years of age at the time of anticoagulation initiation (AF)
Exclusion Criteria	Patients who received anticoagulation therapy for less than 3 months or had a documented heart valve replacement (AF)
Methods	Retrospective analysis of EHR and claims data for AF and MS patients. MTDM program managed pharmacotherapy, with pharmacists trained and credentialed to manage over 16 conditions. Outcomes included ED visits, hospital admissions, and total care costs. Data were adjusted for CCI score and age.
Duration	AF: January 2001–August 2016 MS: January 2014–August 2016
Outcome Measures	Reduction in ED visits and hospitalizations, total care costs
Baseline Characteristics		MTDM Only (n= 7,309)	MTDM/GHP (n= 3,610)	GHP Only (n= 4,206)
	Median age at last visit, yr (IQR)	71 (63–79)	72 (65–79)	71 (62–79)
	Male, no. (%)	3,978 (54%)	1,933 (54%)	2,318 (55%)
	Mean ± S.D. Charlson Comorbidity Index score	3.1 ± 3.3	4.9 ± 3.6	3.8 ± 3.5
Results		MTDM/GHP (n= 3,610)	GHP Only (n= 4,206)	p-value
	Mean no. all-cause ED visits per patient in past yr (95% CI)	0.51 (0.48–0.53)	0.61 (0.57–0.66)	<0.0001
	Mean no. all-cause hospital admissions per patient in past yr (95% CI)	0.33 (0.31–0.35)	0.41 (0.37–0.45)	0.0002
	Mean allowed costs of care ($ thousands) per patient in past yr (95% CI)	24.2 (23.2–25.3)	31.4 (28.7–34.3)	<0.0001
Adverse Events	Not specifically reported in the study
Study Author Conclusions	The Geisinger MTDM program has evolved over 20 years from a single pharmacist-run anticoagulation clinic into a large program focused on managing the health of an ever-growing population. Initial challenges in integrating pharmacists into the Geisinger patient care framework as clinical experts were overcome by demonstrating the MTDM program’s positive impact on patient outcomes.
Critique	The study highlights the successful integration of pharmacists into chronic disease management, demonstrating improved outcomes and cost savings. However, the retrospective design may introduce bias, and the study's findings may not be generalizable beyond the Geisinger Health System. Additionally, the lack of detailed adverse event reporting limits the understanding of potential risks associated with the MTDM program.

References:
[1] [1] Jones LK, Greskovic G, Grassi DM, et al. Medication therapy disease management: Geisinger's approach to population health management. Am J Health Syst Pharm. 2017;74(18):1422-1435. doi:10.2146/ajhp161061

Evaluation of pharmacist-provided medication therapy management services in an oncology ambulatory setting
Design	Retrospective review N= 239
Objective	To determine the effect of formal medication therapy management (MTM) services on pharmacist workload, describe the population receiving MTM, describe the services provided, and determine the reimbursement rate for billed MTM services
Study Groups	All patients (n= 239)
Inclusion Criteria	Patients receiving MTM services from January 1, 2010, to March 31, 2010, in an oncology ambulatory setting
Exclusion Criteria	Not specified
Methods	Retrospective review of MTM charges, using MTM CPT code claims, electronic medical records, and pharmacist MTM logs. Data collected included location of the MTM visit, age, gender, insurance, primary malignancy, comorbidities, home medications, time to complete and document the MTM visit, and rate of reimbursement
Duration	January 1, 2010, to March 31, 2010
Outcome Measures	Primary: Feasibility of documenting and billing for MTM services Secondary: Effect on pharmacist workload, rate of reimbursement for billed MTM services, description of patient population receiving MTM services
Baseline Characteristics		All patients (n= 239)
	Age, years	56 ± 13
	Male	46%
	Number of comorbidities	2 (0–9)
	Number of medications	10 (1–30)
	Patients taking oral chemotherapy	18.8%
	Gastrointestinal cancers	25.1%
	Commercial insurance	66.5%
	Government insurance	28.9%
Results		All patients (n= 239)
	Face-to-face time, minutes	20 (15–127)
	Documentation time, minutes	18 (5–90)
	Total MTM process time, minutes	38 (20–170)
	Reimbursement rate , %	47-79
Adverse Events	Not specified
Study Author Conclusions	MTM in the ambulatory clinic is feasible despite the increase in pharmacist workload from documenting and billing. The increased visibility of clinical pharmacy services justifies the extra time required for formal MTM.
Critique	The study highlights the feasibility of implementing MTM services in an oncology setting and the potential for increased recognition of pharmacists' roles. However, the retrospective design and lack of detailed analysis on patient outcomes limit the ability to assess the full impact of MTM services. Additionally, the study does not address potential barriers to implementation in different settings or the long-term sustainability of the program.

References:
[1] [1] Watkins JL, Landgraf A, Barnett CM, Michaud L. Evaluation of pharmacist-provided medication therapy management services in an oncology ambulatory setting. J Am Pharm Assoc (2003). 2012;52(2):170-174. doi:10.1331/JAPhA.2012.11171

Impact of pharmacist-led medication therapy management in ambulatory elderly patients with chronic diseases
Design	Retrospective cohort study N= 244
Objective	To assess the impact of pharmacist-led medication therapy management (MTM) performed on ambulatory elderly patients with chronic diseases
Study Groups	All patients (n= 244)
Inclusion Criteria	Elderly patients (age ≥65 years) with chronic diseases, such as cardiovascular diseases, diabetes, osteoporosis or gout; received MTM services from pharmacists at least twice a year with complete clinical data
Exclusion Criteria	Not specified
Methods	Patients received MTM services from pharmacists at least twice a year. MTM included analysis, education, and monitoring services. Pharmacists had full access to medical and laboratory records, spending 30-40 minutes per patient to collect comprehensive medical records. DRPs were identified and interventions were made based on the Pharmaceutical Care Network Europe Classification for DRPs V8.03
Duration	January 2016 to June 2018
Outcome Measures	Primary: Detection of drug-related problems (DRPs) Secondary: Clinical outcomes (BP and lipid levels), economic effect (cost of medications)
Baseline Characteristics		All patients (n= 244)
	Age, mean ± SD	72.54 ± 9.96
	Female	143 (58.61%)
	Number of medications taken, mean ± SD	8.76 ± 4.35
	Hypertension	171 (70.08%)
	Heart disease	138 (56.56%)
	Hyperlipidaemia	73 (29.92%)
Results	A total of 525 DRPs among 244 patients, with treatment effectiveness issues making up 53.71% of DRPs. Pharmacists frequently recommended changes in medication, which the study noted as the most common intervention at 48.76%. The acceptance and implementation rates of these interventions were 92.38% and 90.48%, respectively.
		Preintervention	Postintervention	P-value
	SBP mean (mm Hg)	149.08 ± 19.75	134.56 ± 12.38	<.0001
	DBP mean (mm Hg)	84.56 ± 11.34	78.01 ± 9.78	<.0001
	TC (mmol L−1)	6.17 ± 1.34	4.51 ± 0.80	0.027
	LDL-C (mmol L−1)	3.26 ± 1.08	2.54 ± 0.57	<.0001
	TG (mmol L−1)	2.47 ± 0.93	1.69 ± 0.90	<.0001
	Average drug cost per patient for every month (RMB)	387.72 ± 168.48	355.17 ± 180.03	0.009
Adverse Events	Not specified
Study Author Conclusions	Pharmacists had a valuable role in performing MTM services for ambulatory elderly patients, improving clinical outcomes (BP and lipid levels) and achieving cost-saving effects.
Critique	The study demonstrated significant improvements in clinical outcomes and cost savings through pharmacist-led MTM services. However, the retrospective design and lack of a control group may limit the ability to attribute changes solely to the intervention. Additionally, the study was conducted in a single hospital setting, which may affect the generalizability of the findings.

References:
[1] Wang X, Wang S, Yu X, et al. Impact of pharmacist-led medication therapy management in ambulatory elderly patients with chronic diseases. Br J Clin Pharmacol. 2021;87(7):2937-2944. doi:10.1111/bcp.14709

A pharmacist-led pilot program to facilitate deprescribing in a primary care clinic
Design	Prospective pilot study N= 21
Objective	To develop and pilot-test a model in which a community-based clinical pharmacist was incorporated as part of a Medicare Annual Wellness Visit (AWV) to make deprescribing recommendations targeted at potentially inappropriate medications (PIMs) in seniors
Study Groups	Intervention group (n= 21)
Inclusion Criteria	Patients 65 years or older, living in the community, scheduled for an AWV within the study period
Exclusion Criteria	Patients not scheduled for an office visit at a time when an examination room was available for the pharmacist
Methods	A community-based clinical pharmacist provided face-to-face medication reviews for patients older than 65 years as part of their AWV, focusing on deprescribing PIMs. The pharmacist conducted medication reconciliation and comprehensive medication reviews, discussed PIMs with patients, and made recommendations to primary care providers (PCPs)
Duration	August to December 2017
Outcome Measures	Primary: Implementation of a workflow for pharmacist medication review Secondary: Type and acceptance rate of clinical recommendations, healthcare utilization within 6 months, time required for intervention
Baseline Characteristics		All patients (n= 21)
	Male	13 (62%)
	Age, years	75 ± 6
	Total medications	10 ± 3.5
	Average PIMs per Beers Criteria	2 ± 1
Results		Intervention group (n= 21)
	Total deprescribing recommendations	20*
	Overall acceptance rate	20%
	Time per patient encounter, minutes	34 ± 6
	* The pharmacist provided a total of 20 deprescribing recommendations for 13 unique patients
Adverse Events	Not specifically reported
Study Author Conclusions	In this prospective pilot study, a workflow to include a pharmacist medication review to facilitate deprescribing in the primary care setting was tested. Several barriers to integrating the pharmacist into the AWV workflow were encountered. Future pragmatic clinical trials are warranted to improve provider awareness and comfort with deprescribing PIMs in seniors.
Critique	The study highlights the potential role of pharmacists in deprescribing PIMs in primary care settings. However, the small sample size and single-center design limit the generalizability of the findings. The low acceptance rate of recommendations suggests the need for better integration of pharmacists into clinical workflows and stronger relationships with providers. Future studies should focus on overcoming logistical barriers and assessing long-term clinical outcomes.

References:
[1] [1] Clark CM, LaValley SA, Singh R, Mustafa E, Monte SV, Wahler RG Jr. A pharmacist-led pilot program to facilitate deprescribing in a primary care clinic. J Am Pharm Assoc (2003). 2020;60(1):105-111. doi:10.1016/j.japh.2019.09.011

A randomized pragmatic trial of primary care based pharmacist-physician collaborative medication therapy management for hypertension
Design	Randomized, pragmatic, clinical trial N= 166
Objective	To examine blood pressure (BP) control for hypertensive patients managed by a newly formed pharmacist-physician (PharmD-MD) medication therapy management (MTM) team versus usual care in a university primary care clinic
Study Groups	PharmD-MD MTM group (n= 75) Usual care group (n= 91)
Inclusion Criteria	Age 18 years or over, diagnosed with hypertension, most recent BP ≥140/90 mmHg or ≥130/80 mmHg if co-diagnosed with diabetes mellitus, on at least one anti-hypertensive medication, and English speaking
Exclusion Criteria	Did not meet provisions of the clinical collaborative agreement protocol in the judgment of the patient’s physician or the clinical pharmacist
Methods	Hypertensive patients were randomized to a pharmacist–physician collaborative MTM intervention or usual care. In the MTM group, two clinical pharmacists independently conducted four scheduled 30-minute visits at baseline, 3, 6, and 9 months, separate from primary care visits, with additional follow-up as needed. Under a collaborative practice protocol, pharmacists assessed blood pressure, reviewed medical and medication history, set individualized BP goals, ordered or reviewed laboratory tests, and initiated, adjusted, or discontinued antihypertensive medications, with physician consultation available if needed. Encounters were documented in the electronic medical record and communicated to the primary care physician, after which patients returned to usual physician-led hypertension management. Patients in the usual care group continued routine follow-up with their primary care provider.
Duration	July 2010 to June 2012
Outcome Measures	Primary: Change in systolic blood pressure (SBP) at 6 months Secondary: Percent achieving therapeutic BP goal, mean change in diastolic BP, LDL and HDL cholesterol
Baseline Characteristics		PharmD-MD MTM (n= 75)	Usual care (n= 91)
	Age, years	65.4 ± 13.0	69.6 ± 11.4
	BMI, kg/m²	30.2 ± 6.3	29.8 ± 5.7
	Charlson Comorbidity Index	3.1 ± 1.9	4.1 ± 2.6
	Female	35 (47%)	62 (68%)
	Number of anti-HTN medications	1.7 ± 0.8	1.8 ± 1.0
	Total number of medications	8.8 ± 4.2	11.3 ± 5.2
	Abbreviations: BMI, body mass index; HTN, hypertension. Baseline values were not available for all participants for each variable; denominators therefore varied across measures.
Results		PharmD-MD MTM (n= 75)	Usual care (n= 91)	p-value
	Change in SBP at 6 months, mm Hg	-7.1 ± 19.4	+1.6 ± 21.0	0.008
	Change in SBP at 9 months, mm Hg	-5.2 ± 16.9	-1.7 ± 17.7	0.22
	Patients meeting BP goal at 6 months	81%	44%	<0.001
	Patients meeting BP goal at 9 months	70%	52%	0.02
	Changes in LDL and HDL did not differ between groups at 6 or 9 months. The intervention group had fewer primary care provider visits (1.8 ± 1.5 vs 4.2 ± 1.0; p<0.001), with no difference in total visits. Among intervention patients, those continuing pharmacist care through 9 months had greater SBP reduction (−7.8 ± 17.3 vs +1.9 ± 13.8 mm Hg; p =0.03) and DBP reduction (−4.5 ± 9.7 vs +2.8 ± 9.9 mm Hg; p= 0.007) than those returning to primary care provider care, and higher BP goal attainment at 6 and 9 months (88.5% and 78.9% vs 63.6% and 47.4%). Patient satisfaction scores were 92.4 ± 10.9 at 6 months and 92.7 ± 11.0 at 9 months. At baseline, 45.2% of intervention patients had a hypertension-related drug therapy problem, most commonly need for additional therapy (42.4%) or dosage increase (33.3%); about one-third had a medication change at the initial visit. Drug therapy problems and medication changes declined to 20.0% and 11.3% at 6 months, and only two patients required adjustment at 9 months.
Adverse Events	Not assessed
Study Author Conclusions	A pharmacist-physician collaborative medication therapy management service was more effective in lowering blood pressure than usual care at 6 months and 9 months for patients who continued to see the pharmacist. Recognizing the pharmacist’s contribution to improving drug therapy management in collaboration with physicians, and given the shortages of primary care providers and the aging population, incorporating pharmacists in the primary care team to provide MTM services can be a successful strategy for managing medication therapy and improving patient outcomes and possibly extending primary care capacity.
Critique	The study demonstrated the effectiveness of a pharmacist-physician collaborative model in managing hypertension, showing significant improvements in blood pressure control. The pragmatic design aimed to reflect real-world conditions, but the potential for selection bias and the Hawthorne effect should be considered. Additionally, the study did not account for the management of comorbid conditions, which could influence outcomes. Importantly, the comparator was usual care without clear specification of provider type; therefore, a direct comparison between pharmacists and advanced practice providers cannot be made, although the findings still support benefit of pharmacist involvement within primary care.

References:
[1] [1] Hirsch JD, Steers N, Adler DS, et al. Primary care-based, pharmacist-physician collaborative medication-therapy management of hypertension: a randomized, pragmatic trial. Clin Ther. 2014;36(9):1244-1254. doi:10.1016/j.clinthera.2014.06.030

A Randomized Controlled Trial of Team-Based Care: Impact of Physician-Pharmacist Collaboration on Uncontrolled Hypertension
Design	Prospective, single-blind, randomized, controlled trial N= 463
Objective	To evaluate the effectiveness of collaborative management of hypertension by primary care-pharmacist teams in community-based clinics
Study Groups	Control (n= 233) Intervention (n= 230)
Inclusion Criteria	Patients with hypertension and uncontrolled blood pressure identified through the Network’s electronic medical records (EMR) database with a last systolic blood pressure ≥160 mmHg and/or a last diastolic blood pressure ≥100 mmHg
Exclusion Criteria	No blood pressure reading in the chart in the previous 2 years, attended a visit with a pharmacy practitioner in the previous 6 months, or transferred care out of the Network
Methods	Intervention involved pharmacy practitioners actively managing hypertension in primary care offices according to collaborative treatment protocols. Pharmacists reviewed medications, assessed vital signs, screened for adverse drug reactions, provided education, optimized antihypertensive regimens, and scheduled follow-ups. Control group continued usual care
Duration	12 months
Outcome Measures	Primary: Differences in mean systolic and diastolic blood pressures between arms at study end Secondary: Blood pressure goal attainment (<140/90 mmHg), hypertension-related knowledge, medication adherence, home blood pressure monitoring, resource utilization, quality of life, and satisfaction
Baseline Characteristics		Usual care (n= 233)	Intervention (n= 230)
	Age, years	68 ± 13	68 ± 12
	Male	79 (34%)	85 (37%)
	Commercial insurance	72 (31%)	84 (37%)
	Medicare or Medicaid	161 (69%)	146 (63%)
	College education	65 (28%)	64 (28%)
	Current smoker	17 (7%)	20 (9%)
	Body mass index, kg/m²	30 ± 6	29 ± 6
	Co-morbidities Asthma or COPD Diabetes History of stroke Coronary artery disease Renal impairment	27 (12%) 57 (25%) 6 (3%) 43 (18%) 6 (3%)	27 (12%) 59 (26%) 15 (7%) 46 (20%) 8 (3%)
	One or more chronic conditions	103 (44%)	111 (48%)
	Baseline systolic blood pressure*, mmHg	174 ± 15	173 ± 15
	Baseline diastolic blood pressure*, mmHg	92 ± 14	90 ± 14
	*Data acquired from the EMR based on last available blood pressure value in the 24 months prior to study start
Results		Usual care (n= 130)	Intervention (n= 142)	p-value
	Systolic blood pressure Result available from study exit visit ITT (includes last value carried forward)	143 ± 18 148 ± 22	137 ± 17 142 ± 19	0.007 0.002
	Diastolic blood pressure Result available from study exit visit ITT (includes last value carried forward)	78 ± 11 80 ± 12	75 ± 9 77 ± 10	0.003 0.003
	Goal attainment <140/90 mmHg Result available from study exit visit (N/D) ITT (includes last value carried forward) (N/D)	44% (57/130) 42% (97/233)	62% (88/142) 54% (125/230)	0.003 0.005
Adverse Events	Minimal differences between groups in hypertension-related knowledge, medication adherence, quality of life, or satisfaction
Study Author Conclusions	Patients randomized to collaborative primary care-pharmacist hypertension management achieved significantly better blood pressure control compared to usual care with no difference in quality of life or satisfaction.
Critique	The study's strengths include its prospective, randomized, controlled design, large community-based patient population, and multi-site intervention. However, the study may have been subject to contamination bias due to patient-level randomization and co-signing of pharmacist-patient interaction notes by physicians. The low response rate and high withdrawal rate may also limit the generalizability of the findings.

References:
[1] [1] Hunt JS, Siemienczuk J, Pape G, et al. A randomized controlled trial of team-based care: impact of physician-pharmacist collaboration on uncontrolled hypertension. J Gen Intern Med. 2008;23(12):1966-1972. doi:10.1007/s11606-008-0791-x

Integrating Ambulatory Care Pharmacists Into Value-Based Primary Care: A Scalable Solution to Chronic Disease
Design	Cohort study N= 504
Objective	To demonstrate that a retail pharmacy hired and trained clinical pharmacist within a value-based primary care clinic network can improve hypertension (HTN) and type 2 diabetes mellitus (T2DM) control
Study Groups	HTN cohort (n= 43) T2DM cohort (n= 125)
Inclusion Criteria	PCP visit within the past 12 months and PCP approved-referral for pharmacist management
Exclusion Criteria	Pregnancy, hospice, and palliative care
Methods	The impact of clinical pharmacist integration into value-based primary care clinics was evaluated. Clinical pharmacists operated under collaborative drug therapy management agreements and co-managed patients with hypertension and/or type 2 diabetes mellitus. Pharmacist interventions included medication education, therapy initiation or adjustment, laboratory and vital monitoring, adherence interventions, and disease state education delivered via in-person and telehealth visits. Patients were identified through PCP referral or population health screening. Controls consisted of similar patients receiving usual care without pharmacist involvement. Propensity score matching (1:2 ratio) was used to match intervention and control patients based on demographics, clinical characteristics, and comorbidities. Outcomes were measured using electronic medical records and pharmacy claims data. Difference-in-differences analysis using linear mixed effects models evaluated pre- and post-intervention changes in HbA1c and blood pressure between groups, adjusting for covariates and clustering.
Duration	December 1, 2022 to December 1, 2023
Outcome Measures	Pre- to post-index changes in hemoglobinA1c, systolic, and diastolic blood pressure measures
Baseline Characteristics		Patients with diabetes (n= 125)	Patients with hypertension (n= 43)
	Mean age	65.5 ± 1.0	64.7 ± 1.6
	Female	65 (52.0%)	26 (60.5%)
	Race/ethnicity Non-Hispanic White Others	63 (50.4%) 31 (24.8%)	21 (48.8%) 16 (37.2%)
	English language - Yes	122 (97.6%)	42 (97.7%)
	Marital Status Married Other	73 (58.4%) 46 (36.8%)	26 (60.5%) 17 (39.5%)
	Value-based care - Yes	45 (36.0%)	28 (32.6%)
	Frailty - Yes	3 (2.4%)	6 (7.0%)
	Smoking status Former Never	15 (12%) 94 (75.2%)	8 (18.6%) 32 (74.4%)
	Comorbidities - 3+	95 (76%)	36 (83.7%)
	Mean HbA1c	9.0 ± 0.2	-
	Mean SBP	-	145.5 ± 20.0
Results	In the propensity score–matched analysis, pharmacist-managed care was associated with statistically significant improvements in glycemic and systolic blood pressure control compared with usual care. Among patients with type 2 diabetes mellitus, the intervention group experienced a greater reduction in hemoglobin A1c compared with controls (difference-in-differences β −1.16%; 95% CI −1.69% to −0.62%; p< 0.001), with unadjusted reductions of −1.6% in the intervention group versus −0.3% in the control group. Among patients with hypertension, the intervention group demonstrated a significantly greater reduction in systolic blood pressure compared with controls (difference-in-differences β −10.2 mmHg; 95% CI −17.7 to −2.7 mmHg; p< 0.01), corresponding to unadjusted reductions of −16.6 mmHg and −6.3 mmHg, respectively. No statistically significant difference was observed in diastolic blood pressure between groups (difference-in-differences β −2.0 mmHg; 95% CI −6.7 to 2.8 mmHg; p= 0.42), with unadjusted reductions of −5.4 mmHg in the intervention group and −4.0 mmHg in the control group. No adverse events or safety concerns were reported during the study period.
Adverse Events	There were no patient adverse events, provider complaints, or concerns regarding the program throughout the study period.
Study Author Conclusions	Statistically significant reductions in systolic BP and hemoglobinA1c were observed in the pharmacist-managed group compared with matched controls. These results demonstrate that pharmacist integration into a value based primary care clinic may improve measures of chronic disease associated with morbidity and mortality.
Critique	The study provides valuable insights into the effectiveness of pharmacist strategies in managing patients with T2DM and HTN within VBC settings. However, the short follow-up period and reliance on propensity score matching may limit the generalizability of the findings. Additionally, the assumption of parallel trends in DID analyses is challenging to verify, which may affect the validity of the results.

References:
[1] [1] Blood AJ, Saag H, Chesler A, et al. Integrating Ambulatory Care Pharmacists Into Value-Based Primary Care: A Scalable Solution to Chronic Disease. J Prim Care Community Health. 2025;16:21501319241312041. doi:10.1177/21501319241312041