Understanding the Cost Consequences of Pharmacist Roles in Managing Long-Term Illnesses: A Systematic Review

Summary

Objective:

This review looked at how different pharmacist-led services influence medication spending and other economic outcomes for people living with long-term illnesses.

Methods:

To gather the evidence, we followed the PRISMA 2020 approach and a comprehensive search was conducted using multiple sources, including Web of Science, ProQuest, Scopus, the Directory of Open Access Journals, ScienceDirect, PubMed, and Google Scholar. We included studies that examined pharmacist involvement in medication management such as MTM, medication reconciliation, deprescribing efforts, or full medication reviews and that reported some form of cost or economic outcome in chronic disease care. We left out non-English work, conference abstracts, case reports, and papers without accessible full text. After screening all records, 1420 studies met the inclusion criteria. These ranged from randomized trials to cohort studies, pre–post designs, and a few economic modeling analyses. We evaluated methodological quality using the MMAT (2018), and for the modeling work, we applied the Drummond checklist.

Results:

Across the different study types, pharmacist involvement generally led to fewer medication-related problems, better adherence, and more appropriate medication use. Several studies showed that these changes translated into lower overall costs for example, through fewer adverse drug events, fewer hospital visits, or by switching patients to more affordable but clinically appropriate therapy options. Some economic evaluations even suggested that these interventions saved more money than they cost. Programs that combined medication review with patient education, deprescribing, and follow-up tended to show the clearest benefits.

Conclusion:

Taken together, the findings indicate that involving pharmacists more directly in the medication management of individuals with chronic conditions leads to better clinical results and more favorable economic outcomes. These findings support the idea of involving pharmacists more closely within chronic-care teams.

Introduction

Chronic illnesses such as diabetes, musculoskeletal problems, long-standing respiratory conditions, and cardiovascular disease continue to account for a large share of global illness, early death, and healthcare spending [1]. A growing portion of this expenditure now goes toward medicines [2]. With drug prices rising, treatment options expanding, and more people living with several chronic conditions at once, medication regimens have become harder to manage. This added complexity contributes to polypharmacy and makes day-to-day medication use more burdensome, both clinically and financially [3]. Consequently, many individuals encounter substantial out-of-pocket expenses, financial pressure, and challenges in maintaining their treatment regimens [4]. Health systems experience similar pressure, as medication budgets are strained by issues such as inappropriate prescribing, duplicated therapies, harmful interactions, avoidable adverse events, and patients stopping treatment too early [5,6]. Because of these challenges, there is growing attention on approaches that improve the value of medicines that is, achieving the same or better outcomes while reducing unnecessary spending [7].

Pharmacists play an important role in this effort because they can influence both the clinical quality and financial efficiency of medication use [8]. Their work spans a wide range of settings, from community pharmacies and primary care clinics to outpatient specialty services and hospitals [9]. In practice, pharmacists may carry out activities such as medication reviews and reconciliation, MTM services, formulary-aligned substitutions, dose adjustments, deprescribing when medicines no longer offer benefit, and providing adherence support or counseling to patients [10]. They also educate patients on proper medication use and storage; keep an eye out for adverse effects or drug interactions; collaborate with prescribers; and coordinate care alongside nurses and physicians [11]. Increasingly, digital tools including electronic decision support, telepharmacy, and risk-stratification platforms support these roles and help identify patients who may benefit from more careful medication management or opportunities to reduce costs [12].

There are several ways pharmacist involvement can affect medication-related spending [13]. Savings may come from switching costly branded drugs to generics or preferred formulary options; simplifying therapy to cut down on duplicate or unnecessary medicines; adjusting doses to reduce waste; avoiding treatment cascades by preventing adverse drug events; and helping patients stay on effective first-line treatments, which in turn limits complications and avoidable hospital use [14,15,16]. Conversely, some interventions might increase short-term medication spending for example, initiating indicated but previously omitted therapies, switching to higher-cost agents with superior effectiveness, or adding supplies (such as glucose-monitoring strips or inhaler spacers) that enable safer use [10,17,18]. Understanding the net effect on medication costs therefore requires careful evaluation, clear definition of cost perspectives, and attention to time horizons [7].

Economic outcomes in this domain are heterogeneous [8]. Studies report direct medication costs (total pharmacy spend, per-patient monthly costs), patient out-of-pocket payments, acquisition versus administration costs, and program implementation costs [10,4,19]. Others use formal frameworks for economic evaluation, such as budget impact analyses, cost-effectiveness, cost-minimization, or cost-utility [20]. Perspectives vary across the patient, payer, provider, and societal lenses, and time horizons range from weeks to several years [21]. Clinical contexts also differ: hypertension and diabetes management in primary care, heart failure titration clinics, anticoagulation services, COPD/asthma inhaler stewardship, and geriatric polypharmacy reviews each have distinct drug-cost drivers [22,23,24]. This diversity complicates synthesis and limits generalizability if not handled systematically.

Despite numerous reports of pharmacist-led services improving medication appropriateness and safety, the magnitude and direction of their impact on medication costs among patients with chronic diseases remain uncertain. This systematic review therefore aims to (i) compile and evaluate research on how pharmacist interventions affect the cost of medications for adults with chronic illnesses; (ii) characterize which intervention components, settings, and delivery models are associated with cost reductions (or increases); and (iii) explore how study design features, economic perspectives, and time horizons influence observed effects. We focus on direct medication cost outcomes (such as pharmacy spend, per-patient drug cost, out-of-pocket cost), while narratively linking these to relevant clinical or process measures (such as adherence, regimen appropriateness) when reported. In explaining the specific points in care where pharmacists can influence medication-related spending, this review aims to offer practical guidance that may help shape care models, insurance decisions, and policies that support patient-focused and cost-conscious pharmacotherapy for chronic illnesses.

Method

This review follows the PRISMA 2020 reporting guideline. The protocol was developed a priori using a PICOS framework and aligned to Cochrane methods. The articles published from January 2019 to November 2025 with language restriction at search; studies only in English.

The eligibility criteria (PICOS) are as follows: i) Population (P): Adults (≥18 years) with one or more chronic diseases (such as diabetes, cardiovascular disease, COPD/asthma, chronic kidney disease, arthritis) managed in ambulatory, primary care, community pharmacy, outpatient specialty clinics, or transitional-care settings. Exclusions: pediatric populations; acute/short-term conditions only; inpatient-only interventions without post-discharge follow-up. ii) Intervention (I): Pharmacist-led or pharmacist-delivered interventions, alone or within a multidisciplinary team, including (but not limited to) comprehensive medication review/reconciliation, medication therapy management, therapeutic substitution/formulary optimization, dose/duration optimization, deprescribing, adherence counseling/education, collaborative prescribing under protocol, telepharmacy, and decision-support–enabled pharmacy services. iii) Comparator (C): Usual care or another active intervention without a pharmacist component. iv) Outcomes (O): Primary: Direct medication costs (such as total pharmacy spend, per-patient per-month drug cost, out-of-pocket drug expenditure, acquisition/dispensing cost). Secondary (when reported): implementation/program costs; economic evaluation metrics (cost-effectiveness, cost-utility, budget impact); mediators/process measures linked to cost (such as adherence, regimen appropriateness). v) Study design (S): This review considered a range of study designs, including randomized controlled trials (both parallel and cluster formats) as well as quasi-experimental and observational comparative approaches, such as cohort studies, interrupted time series with a comparison group, controlled before-and-after studies, and non-randomized controlled trials. Exclusions: case reports/series, cross-sectional without comparator, editorials, narrative reviews, conference abstracts lacking full text, purely modeling studies with no primary effectiveness data.

Information sources

To locate relevant literature, searches were carried out in seven major databases DOAJ, PubMed, Google Scholar, Scopus, ScienceDirect, Web of Science, and ProQuest using both a combination of controlled subject headings and free-text search terms linked through Boolean operators, proximity operators (where supported), truncation, and field tags. No language limits were applied at the search stage. We reviewed the bibliographies of the selected studies and other relevant reviews to capture any additional studies that might have been missed.

To reflect the review question on pharmacist interventions and medication costs in chronic disease, we adapted the concept blocks as follows: i) Population/context: diabetes, heart failure, hypertension, COPD, asthma, and chronic illness* chronic kidney disease, arthritis; ii) Intervention/profession: pharmacist*, “clinical pharmacist”, “pharmacy service*”, “medication therapy management”, MTM, “medication review”, deprescrib*, telepharmac*; iii) Outcome (cost/economics): “medication cost*”, “drug cost*”, expenditure*, “out-of-pocket”, “pharmacy spend”, economics, “cost analysis”, “budget impact”; iv) Comparison/design (when useful): random*, trial, “controlled”, cohort, “before-after”.

Selection process

After separately screening titles and abstracts for eligibility, two reviewers evaluated the complete text. A PRISMA flow chart was employed to track the screening process and clearly outline the reasons for excluding studies at the full-text stage.

Quality assessment of studies

We assessed methodological quality using the Mixed Methods Appraisal Tool (MMAT, 2018). After a short calibration, 2 reviewers independently screened each study with the 2 MMAT gate questions (clear research question; data appropriately address the question) and then applied the 5 design-specific criteria for the relevant category (qualitative, mixed-methods, non-randomized quantitative, quantitative descriptive, or randomized controlled trials). Each criterion was marked as ‘Yes,’ ‘No,’ or ‘Cannot determine,’ and any disagreements were resolved through discussion. Following MMAT guidance, we did not compute a composite score; instead, we report criterion-level judgments in summary tables (grouped by study design) with brief justifications. In synthesis, all eligible studies were included, but we performed sensitivity analyses that down-weighted or excluded studies with multiple “No/Can't tell” ratings (≥3 within a category) and highlighted findings from studies meeting most criteria (≥4 “Yes”). Extra consideration was given to potential selection bias or confounding, the soundness of the outcome measures, and the completeness of the data, as each of these can influence the accuracy of medication-cost results.

Results

Fig. 1 presents the PRISMA flow diagram summarizing how studies were identified and selected for this review. In total, 1,420 records were located through major databases and online sources such as Science Direct, Web of Science, ProQuest, Google Scholar, Scopus, the Directory of Open Access Journals, and PubMed. Before screening began, 372 entries were removed 348 because they were duplicates and 24 records were removed for administrative reasons, leaving 1,048 items to proceed to the title and abstract screening stage.

Fig. 1.

PRISMA diagram illustrating the study screening and selection process. Source From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71

At this stage, 853 records were removed as they did not fit the review's purpose or thematic focus. The remaining 195 studies were retrieved for closer evaluation, but 56 could not be obtained, including 29 conference abstracts and 27 case studies that lacked sufficient detail for inclusion. This left 139 full-text articles for eligibility assessment. Of these, 120 were excluded, mainly because 92 did not satisfy the predefined inclusion criteria and 28 had no accessible full text. In the end, 19 studies fulfilled all criteria and were included in the final synthesis.

Characteristic features of the study

This review looked at information from the 19 studies we included, paying attention to things like the authors, the countries where the research took place, the study designs, who was enrolled, the chronic conditions being reviewed, the various pharmacist-driven interventions, the comparator groups used, and the reported outcomes, with particular attention to those related to medication costs. The studies came from quite a wide mix of places, including Malaysia, the United States (U.S), Jordan, China, Slovakia, Estonia, Switzerland, the Netherlands, Ireland, and the United Kingdom. This mix of settings shows how different health systems are trying to better understand both the clinical and economic value that pharmacists can add in chronic disease care. The patient groups varied a lot as well. Several studies concentrated on individuals managing long-term conditions such as type 2 diabetes, high blood pressure, or chronic kidney disease, while others involved individuals living with several illnesses at once and taking many medications. A few studies looked at patients receiving treatments like capecitabine, or people with peripheral artery disease, and some involved older adults who were considered frail. The interventions were delivered across many different care settings primary care practices, specialty pharmacies, community programs, nursing homes, tertiary hospitals, emergency departments, and outpatient clinics which shows how many points along the care pathway pharmacists are involved in.

A wide range of methodological designs was represented among the included studies. Several studies employed randomized controlled trial (RCT) designs, such as pharmacist-led educational interventions within Diabetes Medication Therapy Adherence Clinics (DMTACs) in Malaysia, home medication management reviews for chronic disease outpatients in Jordan, and Medication Therapy Management (MTM) interventions for multimorbidity patients with hypertension in China. Other studies used non-randomized comparative designs, including pharmacist-led emergency department medication reviews for adverse drug event related admissions and large-scale U.S. Medicare MTM evaluations involving nearly 700,000 beneficiaries. In addition, multiple studies utilized prospective or retrospective descriptive designs, such as medication reviews in vascular surgery patients in Slovakia, deprescribing services using STOPPFrail in Irish nursing homes, integrated general practice pharmacist pilot evaluations, and specialty pharmacy cost-avoidance analyses in the U.S. Two studies incorporated formal economic modeling, including Markov-based simulations in U.S. hypertensive populations and U.S. diabetes MTM cohorts, demonstrating long-term cost-effectiveness of expanded pharmacist authority. This mix of methods shows how pharmacist-led care can be looked at from many angles, and it also adds more weight to the overall evidence base.

In many of the studies, pharmacists delivered a mix of services things like MTM, medication reconciliation, detailed medication reviews, deprescribing work, patient counseling, and support aimed at preventing adverse drug events. These activities were often paired with clinical monitoring, therapy adjustments, and follow-up check-ins. Together, these kinds of interventions tended to cut down on potentially inappropriate medicines (PIMs) and sort out drug-related problems (DRPs). A lot of the time this meant deprescribing medicines that weren't needed anymore, improving how patients were monitored, and helping people better understand their treatments.

A few examples stood out. In China, pharmacist-led MTM for patients with multimorbidity cut DRPs by about 75% and also lowered medication-related costs over a 12-month period. Another MTM program for oncology patients receiving capecitabine reduced adverse events by roughly 30%. In the United Kingdom, community falls pharmacists helped decrease polypharmacy, anticholinergic burden, and the use of falls-risk-increasing drugs (FRIDs), which led not only to cost avoidance but also, interestingly, some environmental benefits.

Across the different articles, one pattern kept appearing: pharmacist involvement usually produced noticeable cost savings, cost avoidance, or strong cost-effectiveness. For instance, pharmacist-led deprescribing with STOPPFrail in Ireland produced a cost–benefit ratio above 33:1. In Switzerland, DRPs identified by pharmacists resulted in more than €300,000 in cost avoidance in a single year. Specialty pharmacy programs in the United States managed to prevent over $1.5 million in costs in a relatively short time. Emergency-department pharmacist reviews in the Netherlands were also linked to important reductions in medication spending within just 6 months. Broader economic evaluations showed that pharmacist prescribing in hypertension could reduce long-term healthcare costs and improve quality-adjusted life years (QALYs), while Medicare MTM programs in the U.S lowered both medical and pharmacy expenses especially for Black beneficiaries, who saw notable savings and better medication-use quality.

A number of studies also pointed to the importance of patient-focused education and behavior-support components. These tended to improve adherence, treatment understanding, and overall engagement. Home medication-management reviews in Jordan produced high benefit-to-cost ratios by preventing treatment-related issues and lowering medication harm. Community-pharmacy consultations under Medicare Part D in the United States also helped patients feel more satisfied with their care and reduced their out-of-pocket costs.

Altogether, the findings from these 19 studies (as summarized in Table 1) show a fairly consistent picture: pharmacist-led interventions can improve clinical outcomes, raise the quality of prescribing, and generate meaningful cost savings or cost-effectiveness in chronic-disease care. Even though the studies differed in methods and settings, the collective evidence points toward a clear need to include pharmacists more fully in multidisciplinary teams. Future work should try to define pharmacist roles more clearly, evaluate long-term economic outcomes using real-world data, and test scalable models that could support sustainable and cost-efficient healthcare delivery.

Table 1.

An overview of the key characteristics.

Sr No.	Author (Year)	Research setting and context	Design of the Study	Population description and sample size	Chronic Disease(s)	Type of Pharmacist Intervention	Comparator / Control	Outcome Measures	Key Findings (Cost-related)
1	Iqbal et al. (2025) [25]	Malaysia	Randomized Controlled Trial (Multicenter)	400 Type 2 Diabetes Mellitus patients (200 intervention, 200 control) from two tertiary hospitals; 299 completed one-year follow-up	Type 2 Diabetes Mellitus	Pharmacist-led Educational Intervention via Diabetes Medication Therapy Adherence Clinics (DMTACs) structured education on medication use, adherence, diet, exercise, and lifestyle modifications	Usual care per Malaysian Clinical Practice Guideline (2015) without pharmacist-led education	Measures included long-term blood sugar levels, fasting glucose, blood pressure readings, cholesterol markers, and the direct cost of medications.	HbA1c reduced by 2.82% (intervention) vs. 1.43% (control) (p<0.001); Significant cost reduction: additional cost per patient MYR 47.33 (USD ∼10.72) in intervention vs. MYR 236.07 (USD ∼53.45) in control at 12 months; pharmacist intervention led to major savings via discontinuation of unnecessary medications and better glycemic control.
2	Joshi et al. (2025) [26]	United States	Model-based Cost-Effectiveness Analysis (Markov Model Simulation)	Simulated cohort based on 78 real-world patients (mean age 62; 56% female) with T2DM at University of Illinois Health MTM Clinic	Type 2 Diabetes Mellitus (with common comorbidities: hypertension, heart failure, renal failure, stroke)	A pharmacist provided monthly one-on-one sessions focused on improving medication use, supporting adherence, monitoring patient progress, and coordinating care with the healthcare team.	Usual care (no structured pharmacist-led MTM)	Overall lifetime medical expenses, the healthy years gained by patients and the calculation that shows whether one option provides better value than another	Over a lifetime: MTMC total cost $160,145 vs usual care $152,806; QALYs 6.73 vs 6.65; ICER $93,375/QALY cost-effective under $100,000/QALY threshold. Sensitivity and scenario analyses (amputation/blindness, reduced visit frequency) confirmed robustness; cost-effectiveness driven by improved HbA1c (–0.63%) and SBP (–8.2 mmHg)
3	Altawalbeh et al. (2025) [27]	Jordan	Prospective Interventional Study with Cost-Benefit Analysis	142 hospitalized CKD patients (stage 2–5) at two tertiary hospitals (King Abdullah & Princess Basma)	Chronic Kidney Disease (CKD)	A pharmacist carried out medication reconciliation along with a full review at both admission and discharge, identifying and addressing any discrepancies or drug-related issues.	Absence of pharmacist intervention (usual ward practice)	The analysis included total expenditure, realized savings, avoided costs, net economic benefit, and the ratio of benefits to costs.	Total estimated DRP cost avoidance: $83,052 (avg $585 ± 308/patient); service cost: $714; net benefit: $81,871 (avg $577/patient); benefit-to-cost ratio: 115.7 : 1. Major cost avoidance from prevention of drug omissions and dosing errors. Pharmacist intervention highly cost-beneficial even in sensitivity analyses
4	Xue et al. (2025) [28]	China	Retrospective Comparative Study	200 cancer patients (100 intervention, 100 control) receiving capecitabine, followed for 1 year	Cancer patients (mainly colorectal, gastric) on oral chemotherapy (capecitabine)	Oncologist–Pharmacist Joint Clinic Medication Therapy Management (MTM): pharmacists reviewed indications, dosage, adverse effects (AEs), drug interactions, adherence; provided education and follow-up (outpatient/telephone)	Usual oncology care without structured pharmacist MTM	Incidence and severity of AEs (CTCAE v4.0), specific organ-system AE frequency, tumor marker levels	The MTM service resulted in a notable reduction in adverse events about a 30% overall decrease recording 685 events compared with 979 in the control group. Marked declines were seen in gastrointestinal, hematologic, and neurological complications (all p < 0.001). Patients in the MTM group also experienced significantly fewer episodes of pain (p = 0.033) and leukopenia (p = 0.046).Pharmacist intervention prevented discontinuation (6 vs 15 patients). Conclusion: MTM improved safety, reduced AE-related healthcare burden, and optimized therapy management
5	Porubcova et al. (2024) [29]	Slovakia	Prospective Interventional (Single-Centre Pilot Study)	105 vascular surgery inpatients (aged ≥18, taking ≥3 meds) with carotid or lower extremity artery disease	Peripheral Artery Disease (PAD), Hypertension, Dyslipidaemia, Diabetes	A pharmacist completed medication reconciliation and a full medication review at both admission and discharge, reviewing and fixing any medication problems and ensuring patients understood their therapy by having them repeat the key instructions back	No control group (pre–post comparison between admission and discharge)	Outcomes included the classification and frequency of DRPs, the rate of physician agreement with pharmacist interventions, and patients’ comprehension of their pharmacotherapy.	Mean DRPs per patient decreased from 2.3 ± 2.1 to 1.6 ± 1.8 (p < 0.001). Highest reduction in “untreated indications” (↓ 40 → 27%) and “adverse events” (↓ 17 → 14%). Physician acceptance rate: 57.4%, highest at admission (66.1%). Cardiovascular drugs were most affected (41.9% of DRPs). Intervention improved medication safety, adherence, and rational use. Though no direct cost data, the significant DRP reduction implies measurable cost avoidance via prevention of medication errors and adverse events.
6	Crawford et al. (2024) [30]	United Kingdom (Northern Ireland)	Prospective Quantitative Study / Service Evaluation	A total of 92 older adults, all aged 65 or above and living on their own in the community, took part in the study who had been referred to the Community Falls Prevention Service within the hospital trust.	Those recruited were older people flagged as vulnerable to fall-related incidents	The intervention involved a pharmacist-led falls medication review, conducted either in the home or via telephone. The assessment concentrated on FRIDs, anticholinergic burden, bone health using FRAX or DEXA, and prescribing quality as evaluated by the Medicines Appropriateness Index.	Pre–post comparison (before and after pharmacist intervention)	Polypharmacy (mean number of drugs), ACB score, MAI score, number of FRIDs, Eadon grade, cost avoidance, environmental impact	317 pharmacist interventions (93.7% Eadon grade ≥4); mean medicines ↓ 10.4 → 9.6 (–8%), ACB ↓ 4.2 → 2.8 (–33%), MAI ↓ 13.0 → 5.7 (–56%) (all p<0.05). 101 FRIDs deprescribed; annual cost avoidance £40,689–£82,642; return of £1.25–£2.54 per £1 invested; 941 kg CO2 reduction/year from avoided drug waste
7	Jermini et al. (2024) [31]	Switzerland	Partial Economic Evaluation / Return-on-Investment (ROI) Analysis	973 hospitalized internal medicine patients (676 drug-related problems identified; 144 medication reviews conducted)	Mixed chronic and acute conditions in hospitalized adults	Clinical Pharmacist-Led Medication Review (MR) during ward rounds detection of drug-related problems (DRPs), optimization of treatment, prevention of adverse drug events (ADEs), and collaboration with physicians	No control group (economic model applied retrospectively; before–after cost estimation)	Avoided costs of ADEs, total cost of intervention, ROI, sensitivity analysis	Over 12 months, 304,170 € total avoided cost from 676 prevented DRPs; annual pharmacist cost = 112,408 €; net saving = 191,762 € (ROI = 1 : 1.71). Highest savings from preventing untreated indications (€ 127,146) and drug interactions (€ 110,215). Sensitivity analyses confirmed robust cost benefit; even conservative assumptions yielded cost neutrality. Concluded pharmacist-led MR reduced ADE-related hospital expenses and was financially sustainable
8	Jänese et al. (2024) [32]	Estonia	Case Study	101 nursing home residents from 5 facilities using automated dose dispensing (ADD) service	Elderly patients (≥75 years) with polypharmacy (≥6 prescription drugs)	As part of the ADD system, a pharmacist examined each patient's medication regimen to identify issues and improve use, evaluating suboptimal medication use, potential generic substitutions, and dosing inaccuracies.	Pre–post comparison (before vs. after review)	Medication cost saving per patient/year; % cost reduction; determinants of savings	Average annual cost saving € 43.62 per patient (8.27%); if scaled nationally, ≈2% of Estonia's pharmaceutical budget saved. Key drivers: generic substitution, dose correction, and discontinuation of inappropriate drugs.
9	Rahman et al. (2024) [33]	Netherlands	Prospective Controlled Intervention Cost Study	216 hospitalized adults (104 intervention; 112 control) admitted via ED intervention group admitted due to adverse drug events (ADEs)	Mixed chronic diseases (polypharmacy with ADE-related hospitalizations)	Pharmacist-led Medication Review (MR) in the Emergency Department performed by junior ED pharmacists using the STRIP method; included ADE detection, drug-related problem (DRP) identification, medication optimization, and patient counseling (teach-back method)	Usual care (no structured medication review; standard reconciliation and daily clinical pharmacy surveillance)	Cost of intervention, medication cost savings from dose reduction/ discontinuation, sensitivity analysis (varied staff scenarios and duration)	113 medication changes led to € 22,850 cost savings over 6 months vs € 2,299 in controls; net € 61 saving per patient/6 months (after € 138 labor cost). Extrapolated: € 260 annual saving/patient. Cost-neutral if performed by senior pharmacist; higher savings if pharmacy technicians involved. Conclusion: Pharmacist-led reviews for ADE patients reduce drug costs and improve safety even within six months
10	Jungo et al. (2024) [34]	Switzerland	Cluster Randomized Controlled Trial (within-trial economic evaluation OPTICA trial)	The study involved 323 older individuals (≥65 years) presenting with a minimum of three chronic diseases and five long-term medications, drawn from 43 primary care practices.	Coexisting chronic illnesses accompanied by extensive medication use.	The review process relied on the STRIPA digital decision-support platform, through which GPs used the STRIP method to identify and address inappropriate prescribing, then worked with patients to make treatment decisions together.	Usual GP care involving standard medication discussion (no eCDSS support)	Incremental expenditures, QALYs gained, the resulting cost-effectiveness ratio, and analyses across key subgroups	Intervention was dominant mean cost saving CHF 1,857 per patient (95% CI: −3,620 to −93) and incremental QALY +0.026 (95% CI: 0.013 to 0.040) (p<0.05). The benefits were more pronounced in men and in patients aged 65–74 or those 85 and older. The findings remained stable across sensitivity analyses, with most of the cost savings coming from reduced hospital admissions and fewer nursing visits. Overall, the study shows that medication reviews supported by an eCDSS can support healthier day-to-day living for seniors managing multiple diseases and ease the financial burden associated with their treatment
11	Hurley et al. (2024) [35]	Ireland	Descriptive Cost Avoidance Study	The study initially recruited 99 residents aged ≥65 years from six nursing homes linked to general practitioners, of whom 69 were eligible for the final analysis.	Seniors who are physically vulnerable, managing several long-term illnesses, and approaching the end of life.	Pharmacist-led deprescribing using STOPPFrail tool identified potentially inappropriate medications (PIMs), discussed with GPs, and implemented recommendations	Pre–post comparison (before vs. after pharmacist intervention)	Direct cost savings from deprescribed drugs, Costs avoided by preventing adverse drug events, the overall financial gain, and the overall return compared with the cost of delivering the service	Removal of 176 potentially inappropriate medicines generated € 27,162 in direct financial savings and avoided an additional € 61,336 in costs linked to adverse events. The total net benefit reached € 85,909, corresponding to a cost–benefit ratio of 33.2. Sensitivity analyses supported the stability of these findings. Overall, pharmacist-implemented STOPPFrail deprescribing demonstrated strong cost-effectiveness and reduced the risk of adverse drug events.
12	Dixon et al. (2023) [36]	United States	Model-Based Economic Evaluation (Markov Model, 30-year Horizon)	Simulated cohort of adults (mean age 64 years; 49% male) with uncontrolled hypertension based on RxACTION RCT data	Hypertension and cardiovascular risk factors	Pharmacist-Prescribing Hypertension Management Program pharmacists assessed, counseled, prescribed, and titrated antihypertensives with monthly follow-ups (based on RxACTION protocol)	Usual care (standard physician management and education)	Lifetime healthcare costs, cardiovascular (CV) and renal events, the number of extra years individuals lived, the extent to which those years were lived in good health, and the calculation that shows whether the added benefit is worth the added cost	Over 30 years, intervention led to 2,100 fewer CV events and 8 fewer renal disease cases per 10,000 patients; +0.62 QALYs and $10,162 cost savings per person; dominant (better outcomes + lower cost). Population-level savings: $1.137 trillion and 30.2 million life-years gained if 50% uptake. Robust to sensitivity analysis (ICER range $2,093–$24,076). Pharmacist-prescribing was cost-saving and highly cost-effective
13	Tsang et al. (2023) [37]	United States	Retrospective Cross-sectional Cost-effectiveness Study	699,992 Medicare beneficiaries (350,509 MTM enrollees matched with 349,483 non-enrollees) aged ≥65 years	Multiple chronic diseases (≥3) with polypharmacy (≥8 medications)	Under Medicare Part D, MTM services involve pharmacist-led medication reviews, support for adherence, and efforts to optimize drug therapy	Non-enrollees who met MTM eligibility criteria but did not participate	Total healthcare costs (Parts A/B/D), the standard of medication utilization and the metric used to assess incremental cost relative to incremental benefit	Patients receiving MTM incurred less overall healthcare spending ($31,135.89 vs $32,696.69) and showed improved medication-use quality (87.47% vs 85.31%). Both medication costs ($10,681 vs $11,003) and medical expenses ($20,455 vs $21,694) were lower, contributing to the overall savings. The ICER came out to –$72,491, which basically shows that MTM was the clearly superior option from a cost-effectiveness standpoint. The strongest cost savings appeared in Black patients, who saved about $4,000 each on average and also showed better patterns of medication use.
14	Li et al. (2023) [38]	China	Randomized Controlled Trial (Pilot RCT)	101 inpatients (51 intervention, 50 control), aged 45–80, with ≥2 chronic diseases	Hypertension with diabetes, dyslipidemia, heart failure, CKD	Medication Therapy Management (MTM): pharmacist-led review, education, reconciliation, 12-month follow-up	General care (no structured MTM service)	Blood pressure, EQ-5D utility, DRPs, readmission rate, medication cost	Average daily medication therapy cost decreased from RMB 50.58 to 35.43 (P=0.049); DRPs reduced by 75%; improved adherence. MTM lowered costs and improved outcomes.
15	Ó Ciardha et al. (2022) [39]	Ireland	A pilot intervention study carried out prospectively	78 polypharmacy patients (≥10 regular medicines) from one suburban 4-doctor GP practice	Mixed chronic diseases (multiple comorbidities requiring ≥10 drugs per month)	The intervention involved a comprehensive pharmacist-led medication review guided by the Polypharmacy Realistic Prescribing Tool, aimed at detecting potentially inappropriate prescriptions, deprescribing opportunities, and cost savings over 6 months	No comparator group (Pre-post assessment within practice)	Counts of detected PIPs and the deprescribing opportunities that were subsequently implemented; biochemical monitoring improvements; annual drug cost savings	198 PIPs identified (64.1% actioned); 163 deprescribing opportunities (63.8% actioned); monthly drug cost saving € 1,252 (≈ € 15,029 annually). Pharmacist salary € 10,055 → net savings € 4,974 (1st year) and € 20,003 projected over 2 years, ≈ € 256 per patient saved. Integration of practice pharmacist proved feasible, cost-saving, and improved prescribing safety
16	Lankford et al. (2021) [40]	USA	Retrospective observational study	547 pharmacist interventions within specialty pharmacy (hematology/oncology medications)	Patients on high-cost specialty medications (hematology/oncology)	Interventions carried out by clinical pharmacists working in a specialty pharmacy embedded within an integrated health system (EHR access, monitoring, regimen changes)	Usual dispensing without integrated pharmacist review	Number of interventions, cost avoidance (for the health care system)	In total, the 547 pharmacist interventions avoided about $1.5 million in costs. The biggest chunk of savings came from stopping therapies that shouldn’t have been continued ($290,091). A few drugs gilteritinib in particular saved a striking amount per case, close to $28,350 each.
17	Murry et al. (2020) [41]	United States	Retrospective Descriptive Study	318 Medicare Part D beneficiaries identified; 79 used consultation service; subset of 14 analyzed for cost savings	Elderly Medicare Part D beneficiaries with diverse chronic illnesses and significant polypharmacy	Under Medicare Part D, pharmacists offered tailored consultations that involved a detailed review of each patient's medications and insurance plan comparison during open enrollment to optimize out-of-pocket (OOP) costs; included plan education, cost transparency, and assistance with enrollment	No formal control (comparison between continued vs. lowest-cost plan identified through pharmacist review)	Patient satisfaction survey, OOP medication cost difference, plan-switching behavior	Patient satisfaction was high, averaging 4.75 out of 5, and 71% indicated they were certain they would switch plans. Among 14 patients analyzed, all achieved savings, ranging from $72.32–$841.05; median saving = $248.50 per patient annually. Pharmacist consultation resulted in significant OOP cost reduction and improved understanding of plan benefits
18	Al-Qudah RA et al. (2020) [42]	Jordan	Randomized Controlled Trial (RCT)	97 outpatients (48 intervention, 49 control) with ≥1 chronic disease	Hypertension, Diabetes, Asthma, Hyperlipidemia, others	Home Medication Management Review (HMMR) clinical pharmacist identified treatment-related problems (TRPs), made recommendations to physicians, and provided patient education	Usual care (no pharmacist-led review or education)	The evaluation covered how much spending was reduced or avoided, the total economic advantage, and how benefits compared with the costs involved	Operating the intervention cost JD 764 per month, yet it returned JD 4,570 in benefits each month—nearly six times the investment. When projected annually, the net financial gain was JD 45,669 (US $64,393). Overall, the pharmacist intervention proved cost-beneficial and helped reduce treatment-related problems
19	Cardwell et al. (2020) [43]	Ireland	Non-randomised Pilot Study	786 patients with ≥1 prescribing issue; 96 older adults (≥65 years, polypharmacy) participated in patient-reported outcomes	Multimorbidity and polypharmacy in primary care patients	General Practice Pharmacist (GPP) Integration pharmacist (10 h/week for 6 months) conducted medication reviews, identified high-risk prescribing, deprescribing opportunities, and cost-ineffective prescribing; provided feedback to GPs, audit support, and education	No formal control group (pre–post intervention feasibility study)	Number of prescribing issues identified and resolved, medication costs, assessments of quality of life using the EQ-5D-5L and EQ-VAS tools, along with treatment burden evaluated through the MTBQ	Pharmacists identified 1,521 prescribing issues across 786 patients; 59.8% of deprescribing issues and 5.8% of cost-related issues addressed. Estimated cost savings € 56,669 (≈ € 57,000 annually) largely from discontinued drugs (€ 43,681). Cost of intervention: € 54,080 (pharmacist salary + GP/practice time); overall net saving ≈ € 2,600 in first year. Demonstrated feasibility, high uptake for safety-related changes, and potential long-term economic benefit through improved prescribing

Quality assessment

The methodological quality of the 17 included studies was appraised using the Mixed Methods Appraisal Tool (MMAT, 2018), and overall, the studies demonstrated good to high quality across the assessed domains as shown in Table 2. Across the included studies, research questions were generally articulated explicitly, and the data gathered aligned appropriately with those aims well suited to answering them (S1–S2), indicating strong foundational rigor. The randomized controlled trials included in the review exhibited generally robust procedures, including appropriate randomization, comparable baseline characteristics, and complete outcome data, although blinding of outcome assessors was frequently unclear or absent. Non-randomized studies commonly demonstrated appropriate measurement methods and complete follow-up, but often lacked adjustment for confounding factors. In the quantitative descriptive studies, pharmacists generally used appropriate sampling methods and relied on validated instruments to identify drug-related problems; however, representativeness and nonresponse bias were frequent limitations, particularly in single-site studies or those with low participant follow-up. Overall, the MMAT appraisal reflects that despite some methodological constraints most notably limited blinding, representativeness issues, and occasional nonresponse bias the included studies provide methodologically sound evidence indicating that when pharmacists take an active role in caring for individuals with long-term illnesses, patients tend to do better clinically and the healthcare system functions more efficiently.

Table 2.

Mixed Methods Appraisal Tool (MMAT), version 2018.

Category of study designs	Methodological quality criteria	Iqbal et al. (2025)	Altawal-beh et al. (2025)	Xue et al. (2025)	Porubcova et al. (2024)	Crawford et al. (2024)	Jermini et al. (2024)	Jänese et al. (2024)	Rahman et al. (2024)	Jungo et al. (2024)	Hurley et al. (2024)	Tsang et al. (2023)	Li et al. (2023)	Ó Ciardha et al. (2022)	Lankford et al. (2021)	Murry et al. (2020)	Al-Qudah RA et al. (2020)	Cardwell et al. (2020)
Screeni ng questions	S1. Are there clear research questions?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
	S2. Do the collected data allow to address the research questions?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Quantita tive Randomized Controlled trials	2.1. Is randomization appropriately performed?	Yes	N/A	N/A	N/A	N/A	N/A	N/A	N/A	Yes	N/A	N/A	Yes	N/A	N/A	N/A	Yes	N/A
	2.2. Are the groups comparable at baseline?	Yes	N/A	N/A	N/A	N/A	N/A	N/A	N/A	Yes	N/A	N/A	Yes	N/A	N/A	N/A	Yes	N/A
	2.3. Are there complete outcome data?	Yes	N/A	N/A	N/A	N/A	N/A	N/A	N/A	Yes	N/A	N/A	Yes	N/A	N/A	N/A	Yes	N/A
	2.4. Are outcome assessors blinded to the intervention provided?	Can’t tell	N/A	N/A	N/A	N/A	N/A	N/A	N/A	Can’t tell	N/A	N/A	No	N/A	N/A	N/A	No	N/A
	2.5 Did the participants adhere to the assigned intervention?	Yes	N/A	N/A	N/A	N/A	N/A	N/A	N/A	Yes	N/A	N/A	Yes	N/A	N/A	N/A	Yes	N/A
Quantita tive non-randomi zed	3.1. Are the participants representative of the target population?	N/A	N/A	Can’t tell	N/A	N/A	N/A	N/A	Yes	N/A	N/A	Yes	N/A	N/A	N/A	N/A	N/A	N/A
	3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)?	N/A	N/A	Yes	N/A	N/A	N/A	N/A	Yes	N/A	N/A	Yes	N/A	N/A	N/A	N/A	N/A	N/A
	3.3. Are there complete outcome data?	N/A	N/A	Yes	N/A	N/A	N/A	N/A	Yes	N/A	N/A	Yes	N/A	N/A	N/A	N/A	N/A	N/A
	3.4. Are the confounders accounted for in the design and analysis?	N/A	N/A	No	N/A	N/A	N/A	N/A	No	N/A	N/A	Yes	N/A	N/A	N/A	N/A	N/A	N/A
	3.5. During the study period, is the intervention administered (or exposure occurred) as intended?	N/A	N/A	Yes	N/A	N/A	N/A	N/A	Yes	N/A	N/A	Yes	N/A	N/A	N/A	N/A	N/A	N/A
Quantita tive descriptive	4.1. Is the sampling strategy relevant to address the research question?	N/A	Yes	N/A	Yes	Yes	Yes	Yes	N/A	N/A	Yes	N/A	N/A	Yes	Yes	Yes	N/A	Yes
	4.2. Is the sample representative of the target population?	N/A	Can’t tell	N/A	Can’t tell	Can’t tell	Can’t tell	Can’t tell	N/A	N/A	Can’t tell	N/A	N/A	Can’t tell	Can’t tell	No	N/A	Can’t tell
	4.3. Are the measurements appropriate?	N/A	Yes	N/A	Yes	Yes	Yes	Yes	N/A	N/A	Yes	N/A	N/A	Yes	Yes	Yes	N/A	Yes
	4.4. Is the risk of nonresponse bias low?	N/A	Can’t tell	N/A	No	No	Yes	Yes	N/A	N/A	No	N/A	N/A	No	Yes	No	N/A	No
	4.5. Is the statistical analysis appropriate to answer the research question?	N/A	Yes	N/A	Yes	Yes	Yes	Yes	N/A	N/A	Yes	N/A	N/A	Yes	Yes	Yes	N/A	Yes

Beyond the MMAT assessment, which we used to judge the methodological quality of primary empirical studies, we also applied the Drummond 10-point checklist to assess the economic modeling studies in this review. The Drummond tool is widely recognized internationally and is specifically designed for evaluating economic analyses such as cost-effectiveness, cost-utility, and cost-benefit studies

Two of the included studies (Joshi et al., [26] 2025 and Dixon et al., [36] 2023) were purely economic model–based cost-effectiveness analyses using Markov simulations and did not involve human participants or primary data collection. Since the MMAT framework applies only to empirical qualitative, quantitative, and mixed-methods designs, it could not be used for economic modeling studies. These were instead assessed with the Drummond 10-item checklist, a widely accepted standard for evaluating economic evaluations. This ensured that the model-based studies were reviewed using criteria suited to their methodology.

Discussion

Our review shows a fairly steady pattern across the evidence. When pharmacists are involved in the ongoing management of chronic illnesses, the economic outcomes tend to be positive. In many cases this comes from direct reductions in medicine costs, avoided expenses from problems that never occurred, or longer-term gains in cost-effectiveness across different settings, patient groups, and types of interventions. Looking at the 19 studies from ten countries, pharmacist participation whether through medication reviews, deprescribing efforts, MTM services, reconciliation, or closer integration into everyday practice was almost never linked to higher costs. Instead, it was usually associated with clear savings or at least favorable cost-effectiveness from the viewpoints of patients, health providers, or payers. These financial benefits were closely tied to improvements in how medications were prescribed, fewer medication-related issues and inappropriate prescriptions, and better adherence and monitoring. The collective findings demonstrate that pharmacists add significant value not only clinically but also economically in caring for people with long-term conditions.

Patterns across different intervention types and care settings

One clear strength of this evidence base is that it covers a wide range of pharmacist roles, which makes it easier to compare how different kinds of interventions work in different care settings. Disease-focused MTM and educational programs such as DMTAC-based diabetes education in Malaysia by Iqbal et al. [25] and MTM clinics for diabetes and multimorbidity in China and the U.S (Li et al., [38] Joshi et al. [26]) showed that structured pharmacist engagement improved intermediate clinical outcomes (such as hemoglobinA1c [hbA1c], blood pressure) while simultaneously reducing medication costs or rendering care cost-effective over longer horizons. In parallel, a study on pharmacist-prescribing programs for hypertension by Dixon et al. [36] and large-scale MTM for Medicare beneficiaries by Tsang et al. [37] demonstrated that expanding pharmacist scope beyond traditional dispensing to active therapeutic management can be economically dominant, lowering overall healthcare costs while improving outcomes.

Sr no.	Drummond Criteria	Joshi et al. (2025)	Dixon et al. (2023)
	Is there a clearly stated research question?	Yes	Yes
	Are competing alternatives clearly described?	Yes	Yes
	Is the effectiveness of the intervention established?	Yes	Yes
	Are all relevant costs identified?	Yes	Yes
	Are all relevant outcomes identified?	Yes	Yes
	Are costs and outcomes measured accurately?	Yes	Yes
	Are costs and outcomes valued credibly?	Yes	Yes
	Is discounting performed where appropriate?	Yes	Yes
	Is an incremental analysis of costs and outcomes performed?	Yes	Yes
	Was sensitivity analysis performed?	Yes	Yes

In contrast, some studies focused on deprescribing and polypharmacy-focused services in frail older adults and nursing home residents generated very high returns on investment through removal of low-value medicines, generic substitution, and regimen simplification [35,39,32,43]. These interventions tended to deliver immediate and easily quantifiable drug-cost reductions, with additional modeled savings from avoided adverse drug events (ADEs). Similarly, pharmacist involvement in high-cost specialty pharmacy and ED-based medication review for ADE-related admissions emphasized cost avoidance through prevention of wastage (such as early discontinuation of ineffective or unnecessary therapy) and optimization during acute transitions [33,40].

Other investigations by Porubcova et al. [29] and Jermini et al. [31] showed that integrated ward-round participation and systematic DRP identification can translate into sizeable cost avoidance by preventing untreated indications, dosing errors, and clinically significant drug interactions. Meanwhile, in the study of Crawford and Cardwell, community-based falls pharmacists and general practice pharmacists highlight how pharmacist presence within multidisciplinary primary-care teams facilitates deprescribing FRIDs, reducing anticholinergic burden and improving medication appropriateness, with associated savings and even environmental benefits [30,43]. Looking at the studies as a whole, it seems clear that pharmacists add financial value in both community and hospital settings when they're allowed to take an active role in checking, refining, and following up on medication regimens.

Cost outcomes, perspectives, and time horizons

In the collected evidence, economic outcomes were evaluated in numerous ways, which matters when trying to compare results across different settings. In several cases, the interventions focused mainly on direct medication expenses from either the patient or payer perspective, showing that pharmacist involvement can lower individual drug costs through approaches such as dose adjustments, switching to generics, or deprescribing medicines that are no longer needed [38,33,41]. Other studies used a broader healthcare-system lens, capturing outcomes like hospital admissions, emergency department visits, and longer-term complications. For instance, the OPTICA trial by Jungo et al., [34] which used an electronic clinical decision support system (eCDSS) to support medication review, and the hypertension and diabetes Markov models described by Joshi et al. [26] and Dixon et al. [36] suggested that pharmacist-led optimization might keep medication costs steady or even increase them slightly while reducing expensive downstream events. When these avoided events are factored in, the overall impact was still net savings with favorable cost-effectiveness ratios.

It is useful to distinguish between these short-term medication-budget changes and the longer-term system-level consequences. Some interventions, especially those that strengthen evidence-based therapy (for example, adding cardioprotective agents or refining antihypertensive treatment), can raise immediate drug spending but still be economically reasonable once reductions in cardiovascular complications, hospital stays, or disability over time are considered. In contrast, deprescribing-oriented programs tend to show immediate and easily measurable drops in pharmacy spending, although their longer-term benefits on “hard” clinical outcomes are less commonly quantified and are often estimated through cost-avoidance models instead.

There was also considerable variation in the analytic perspectives taken across studies. A number were based on provider or health-system views for example, work from internal medicine departments or specialty pharmacies while some focused directly on patients' out-of-pocket costs, including studies aimed at optimizing Medicare Part D coverage. Others applied broader payer perspectives that included both medical and pharmacy expenditures. Although this heterogeneity makes it difficult to compare cost estimates directly, the overall picture suggests that pharmacist interventions generally do not shift costs in a negative way for any particular stakeholder. Instead, they tend either to produce “win–win” scenarios (savings for both payers and patients) or to generate modest cost increases that are justified by improved health outcomes and quality-adjusted life years.

Linking economic benefits with clinical and prescribing outcomes

Across the included studies, economic benefits were tightly interwoven with improvements in clinical outcomes and prescribing quality. In diabetes and multimorbidity cohorts, pharmacist-led MTM reduced HbA1c, blood pressure, and other risk factors, which in turn drove modeled reductions in cardiovascular events and long-term cost savings [25,26,36] Xue et al. [28] reported that pharmacist–oncologist MTM clinics led to fewer and less severe treatment-related adverse events in oncology patients, likely decreasing additional medication use, dose reductions, and treatment discontinuations that would otherwise raise costs and compromise outcomes.

Deprescribing and polypharmacy interventions demonstrated that removing PIMs, FRIDs, and unnecessary drugs can reduce DRP burden, lower anticholinergic load, and improve monitoring factors strongly associated with falls, hospitalizations, and ADEs. Some studies that explicitly quantified ADE cost avoidance showed that the majority of economic benefit derived from preventing high-impact yet avoidable events, such as serious drug interactions, incorrect dosing in CKD, or omission of essential therapy at transitions of care [27,30,35].

Moreover, several interventions emphasized patient-centered education, shared decision-making, and adherence support. Improved adherence to cost-effective first-line therapies for example, antihypertensives and diabetes medications paradoxically may increase medication consumption in the short term but is expected to reduce complications and hospital use later, a pattern captured in modeling studies by Joshi et al., [36] Dixon et al., [26] and large-scale observational analyses by Tsang et al. [37] The fact that the clinical, process, and economic benefits all point in the same direction makes it clear that pharmacist-led services are doing more than just trimming costs. They actually add value and fit well with the idea of providing high-quality, patient-focused care.

Consequences for healthcare policy and practical implementation

When you look at the findings together, they suggest that bringing pharmacists more fully into chronic disease care pathways is a practical and financially sensible approach for health systems that want to improve overall value. Several implications emerge: i) Investment in clinical pharmacy roles pays off: Across hospitals, primary care clinics, community pharmacies, and specialty services, the cost of pharmacist salaries and program delivery was usually recovered and in many cases exceeded through reductions in medication waste, adverse drug events, and avoidable medical spending. Because of this, policy-makers and payers should see clinical pharmacy services as a worthwhile investment, not just an optional add-on. ii) Expanding pharmacists' scope of practice can create system-wide savings: In settings where pharmacists are allowed to prescribe, adjust doses, or deprescribe under collaborative arrangements, studies reported better disease control and meaningful long-term cost reductions for example, in hypertension management. Updating regulation, reimbursement structures, and training requirements to support these advanced responsibilities could help health systems capture even more value. iii) Targeting high-risk, high-cost groups maximizes impact: Interventions focusing on older adults with multimorbidity, patients with ADE-related admissions, individuals using high-cost specialty drugs, and those with complex polypharmacy produced some of the largest absolute savings. Health systems may wish to prioritize these populations when implementing or scaling pharmacist services. iv) Equity and patient-centered care need to stay at the forefront: Programs that helped patients choose more suitable Medicare plans, increased access to affordable generics, or provided tailored education and adherence support showed clear reductions in out-of-pocket spending and better patient satisfaction. By easing economic pressures and guiding patients to make informed choices, these models contribute to more equitable and patient-centered care

For low- and middle-income countries, especially those that don't yet have a fully developed clinical pharmacy workforce, the evidence in this review suggests that even fairly simple pharmacist-led activities like doing medication reconciliation for CKD patients or carrying out home-based medication reviews can offer substantial economic benefit. At the same time, any implementation will need to be shaped around local realities, including the available workforce, formulary limitations, and the way services are financed.

Strengths and limitations of the review

The review is enhanced by relying on a fresh, up-to-date search period, a broad database strategy, clearly defined PICOS eligibility criteria, and independent dual-reviewer screening with quality appraisal using the MMAT and Drummond tools. Focusing specifically on medication-cost outcomes rather than combining all healthcare costs together also increases the practical value of the findings for decision makers.

Nonetheless, important limitations merit consideration. First, substantial clinical and methodological heterogeneity across studies spanning different diseases, settings, intervention components, and economic perspectives precluded meta-analysis and limits precise quantification of effect sizes. Second, much of the existing evidence comes from wealthier nations where pharmacy systems are already highly established, which may constrain generalizability to resource-limited settings. Third, cost estimates were not standardized to a common currency year, and several cost-avoidance analyses relied on assumptions about event probabilities and costs that may differ across contexts and over time. Fourth, potential publication bias cannot be excluded: programs that fail to demonstrate cost savings may be less likely to be published. Finally, although MMAT ratings were generally favorable, issues such as lack of blinding, limited representativeness, and unmeasured confounding mean that some observed economic benefits should be interpreted with caution.

Directions for future research

Future studies should build on this foundation in several ways. Robust, adequately powered randomized or quasi-experimental designs are still needed in underrepresented settings and disease areas, the issue is even more pronounced in LMICs and in conditions like chronic lung disease and chronic pain, where drug costs account for a significant portion of overall care costs. Having more consistent reporting of cost categories, analytic perspectives, and time horizons preferably following international guidelines for economic evaluations would make it much easier to compare findings across studies and could even allow for future meta-analyses. Longer follow-up periods, along with the use of administrative data, would also help capture the full pattern of costs and outcomes over time, particularly in cases where pharmacist interventions strengthen evidence-based therapy and may shift costs in the short term.

It would also be useful for future work to account directly for the resources required to implement these interventions, including issues of scale and how widely they are adopted in real-world settings, since these factors are essential for designing financing models that can be sustained. In addition, more attention is needed on equity impacts such as how effects might differ by socioeconomic status, race or ethnicity, rural versus urban residence, or insurance coverage. Finally, studies should look more closely at how digital tools like eCDSS platforms, telepharmacy, and risk-stratification systems can be woven into everyday pharmacist workflows in ways that maximize both clinical and economic benefits.

In conclusion, when pharmacists take an active role in the care of people with chronic conditions, clinical outcomes generally improve, and costs tend to go down as well. Across a range of settings and patient groups, pharmacists helped patients use their medicines more effectively, reduced drug-related problems, and contributed to noticeable savings or avoided costs. Even though the studies differed in design and approach, the overall picture still points in the same direction: pharmacists play an important part in delivering high-value care, especially for patients who are at higher risk, taking many medications, or dealing with several chronic illnesses at once. Bringing pharmacists more fully into healthcare teams and expanding what they are allowed to do appears to be a practical and cost-sensible way to improve outcomes while making better use of limited healthcare resources.

Acknowledgements

The author sincerely appreciates the generous support provided by the Deanship of Scientific Research at King Khalid University for this study. The authors also extend their gratitude to colleagues and collaborators for their valuable insights, constructive feedback, and continuous support throughout the development of this manuscript. Editorial refinement and language polishing were conducted with careful oversight to ensure clarity and accuracy.

Disclosure statement

No generative artificial intelligence (AI) tools were used for data collection, analysis, or figure creation in this study. Limited AI-based assistance (such as grammar and language refinement) was used under full author supervision for improving readability. The author take full responsibility for the integrity and accuracy of the content of this manuscript.

Funding Information

The authors extend their appreciation to the Deanship of Research and Graduate Studies at King Khalid University for funding this work through Large Research Project under grant number RGP2/590/46.