Pharmacists play a key role as drug experts in many healthcare systems. Over the last 20 years, the pharmacist’s role in many settings has shifted in focus from drug dispensing to patient-centered pharmaceutical care [37
]. Pharmacist interventions such as patient counseling, education, medication management, and referrals to other healthcare professionals have led to significant improvements in blood glucose levels among diabetic patients, blood pressure levels among antihypertensive patients, and cholesterol levels among hyperlipidemic patients [39
]. From our review, we found that compared to “usual care,” a pharmacist intervention that included patient counseling, education, QUS, and physician contact increased central DXA testing and calcium intake among individuals at high risk for osteoporosis. Although not specifically identified within the studies included in our review, a recent RCT identified that DXA testing among women aged 45–54 years significantly increased the use of osteoporosis pharmacotherapy and supplementation with calcium and vitamin D [42
]. Further research is needed to determine if pharmacy interventions may also improve osteoporosis treatment initiation.
Result from studies included in our review support the use of heel QUS measurement as a feasible BMD screening method that can be utilized by pharmacists [36
]. Although QUS is no better than questionnaires based on simple risk factors, such as age, body weight, and sex in predicting those likely to have low BMD [43
], offering a clinical service such as BMD measurement may be important for the success of pharmacy-led osteoporosis interventions. In fact, one of the trials included in our review that compared patient satisfaction between two different pharmacist interventions found that peripheral BMD testing was important for patient recruitment and satisfaction [34
]. Further research is needed to clarify the importance of BMD measurement on the success of community-based osteoporosis interventions.
Our study has many strengths, including a thorough systematic search of the literature, having two independent reviewers search for an abstract data and having a third author to resolve discrepancies. We also focused on RCT study designs. Nonetheless, our results are limited to the quality and generalizability of the RCT studies identified. In fact, due to high risk of bias in two of the RCTs under review, non-experimental studies may have yielded similar quality results. If no plan exists to disseminate interventions outside a local setting, lower-quality evidence may be acceptable in quality improvement [44
]. Evidence from non-experimental studies may thus be informative for local quality improvement interventions.
Our study is also limited by qualitative assessment of risk of bias, which we ascribed as low or high risk based on our assessment of whether or not evidence existed to suggest that results may be biased. We had originally considered two quality assessment tools [45
] used in prior reviews of pharmacist interventions [8
]. However, upon the application of these quality assessment tools, we found that neither differentiated between the studies well. The first largely focused on the quality of reporting methods [45
], and we found the second to be more relevant to drug interventions than healthcare interventions [46
]. We therefore decided to examine the risk of bias qualitatively grouped under the main headings of information bias and selection bias, and ascribed “low risk” when we noted little evidence of potential bias, and “high risk” when we noted some evidence of potential bias. Further work to provide better quality assessment tools for healthcare interventions is needed.
Although our findings suggest that community pharmacist interventions may help to improve the identification of individuals at risk for osteoporosis through improved DXA testing, further study is important to determine the feasibility of interventions in community pharmacies. We note that the two trials with positive findings were completed in: (1) a network of pharmacies that had pharmacists with advanced training and experience in research participation [35
] and (2) community pharmacies within the same pharmacy chain [36
]. In addition, the one other RCT included in our review had excluded pharmacies deemed to have too few staff or insufficient space [34
]. Therefore, the generalizability and feasibility to other settings need to be explored. We also note that none of the studies examined the impact of the pharmacist interventions on osteoporosis treatment adherence or considered pharmacists’ experience or satisfaction with the osteoporosis management programs. Recent reviews of the literature identify that strategies that enhance patient and healthcare provider communication and treatment follow-up may be key to improving adherence to osteoporosis pharmacotherapy [5
]. Further study is thus important to identify the impact of pharmacy interventions on treatment initiation and adherence to therapy, as well as to examine the feasibility of osteoporosis management in community pharmacy. Interventions in osteoporosis management by physicians, physiotherapists, nurses, dieticians, and other healthcare professionals working in teams have helped to improve treatment adherence and calcium intake among community-dwelling women [5
] and increase BMD testing and osteoporosis treatment rates in patients post-fracture [4