Key stakeholders' experiences with the implementation of medication reviews in community pharmacies: a systematic review.

Background: Many unplanned hospital admissions occur due to adverse drug events which may be reduced by medication reviews (MRs), a pharmacist intervention that aims to optimise drug use. However, evidence suggests that MRs are not widely available in community pharmacies. Purpose: The aim of this systematic review was to critically appraise, synthesize and present the available evidence of stakeholders' experiences with the implementation of MRs, and to identify facilitators and barriers to MR implementation in community pharmacy. Method: A systematic search in 4 databases was conducted in June 2019. Articles in the English, Spanish or German language published in the previous 15 years were included. Key search terms were related to implementation, pharmac*, medication review, facilitator and barrier. Included participants were pharmacists, doctors, patients and other external stakeholders. Two researchers independently performed the screening and quality assessment of the articles. Synthesis and analysis were based on the Consolidated Framework of Implementation Research (CFIR), thus organizing experiences and influences to implementation in the domains "intervention", "outer setting", "inner setting=pharmacy", "characteristics of individuals=pharmacists" and "process". Findings: 23 studies from 9 high income countries met the inclusion criteria. Participants of the studies were mainly employed pharmacists (n=12 studies), doctors (n=3 studies) and patients (n=3 studies); the remaining studies reported other or several stakeholders' perspectives. Key influences from the 'outer setting' were adequate remuneration and a clear mandate from health authorities. Both could manifest as barrier or facilitator and impacted on influences from other domains such as resourcing ('inner setting') or engaging patients and doctors ('process'). While the advantage of MRs ('intervention') over usual care was appreciated across all stakeholder groups, the complexity of MR implementation and the accompanying excessive documentation was perceived as a barrier. Facilitators from within the pharmacy ('inner setting') were a motivated and well-functioning team. Leadership engagement was reported as fundamental since managers shaped the culture of the pharmacy and allocated resources. Pharmacists ('individuals') were receptive to the idea of conducting MRs as a new clinical task especially after additional MR-training had boosted their self-confidence and efficacy. Conclusion: This SR highlighted the complexity of MR implementation in community pharmacy and added to the understanding of several stakeholders' perspectives. However, pharmacy owners who (in countries like Germany) decide whether to implement MRs in their pharmacy were not represented in the literature and their views and experiences need to be investigated in future research