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Abstract

  1. Top of page
  2. Abstract
  3. COMMUNITY PHARMACIES
  4. ACADEMIC DETAILING
  5. INTEGRATED HEALTH SYSTEMS
  6. PHYSICIAN OFFICE PRACTICES
  7. INCORPORATING PHARMACY SERVICES INTO PHYSICIANS' PRACTICES
  8. CONCLUSION
  9. References

The goals for hypertension in the publication Healthy People 2010 require a much more intensive approach in order to achieve desired blood pressure control rates. The pharmacist is uniquely positioned in the health care system to assist with improving blood pressure control by utilizing strategies to solve medication-related problems. Studies within integrated health systems have demonstrated that when pharmacists are included as members of health care teams, control rates for hypertension increase. In addition, drug interactions, nonadherence, and costs can be reduced. The authors suggest that incorporating a pharmacist or some services typically provided by traditional pharmacists into physician practices can improve blood pressure control. This review summarizes studies involving pharmacist participation in hypertension management and provides recommendations for obtaining pharmacist involvement.

In 1990, the US Department of Health and Human Services set many health-related goals for the United States, including control of blood pressure to lower than 140/90 mm Hg in 50% of all individuals with hypertension.1 Unfortunately, phase 2 results from the Third National Health and Nutrition Examination Survey (NHANES III), 1991–1994, found that blood pressure was controlled in only 27.4% of hypertensive patients aged 18–74.1 Although the goal for Healthy People 2000 was not achieved, the updated and more current Healthy People 2010 goals again call for blood pressure control (<140/90 mm Hg) in 50% of all individuals with hypertension.2 This goal will be very difficult to achieve, in light of data that control rates may have slipped to as low as 16.6% (in Olmsted County, MN3), or 23% in a subsample of NHANES III participants.4 Many guidelines committees now recommend still lower treatment goals for patients with diabetes (<130/80 mm Hg),5,6 renal impairment, or congestive heart failure (<130/85 mm Hg).1 Accordingly, it will be even more difficult to achieve blood pressure control as recommended in national guidelines.1,5,6 Some authors have called the treatment of hypertension a failure and in urgent need of improvement.3,7–9 Innovative strategies must be found to help improve blood pressure control rates.

A recent article by Hyman and Pavlik4 examined the NHANES III data and found that most cases of uncontrolled hypertension occur in patients who are over 65 years of age who have good access to health care and relatively frequent contact with physicians. Of patients over age 65 with treated but uncontrolled hypertension, 87.6% had a systolic blood pressure over 140 mm Hg, while only 1.3% had a diastolic blood pressure over 90 mm Hg. In comparison, 66.1% of the patients aged 45–64 years with treated but uncontrolled hypertension had a systolic blood pressure over 140 mm Hg and 2.8% had a diastolic blood pressure over 90 mm Hg. Surprisingly, these patients had visited a physician, on average, six times in the previous 12 months. This poor control of blood pressure despite so many physician-patient interactions may be due to a variety of factors, including the number of patient office visits and time constraints that hinder the physician's ability to address hypertension when it is not the patient's chief complaint.

In order to achieve blood pressure goals, a much more intensive approach to the identification, management, and control of hypertensive patients is necessary. It is also critical that information systems be developed to identify and track hypertensive patients who drop out of the system by not returning for follow-up visits or obtaining antihypertensive medications. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI) concludes that, “In particular, pharmacists should be encouraged to monitor patients' use of medications, to provide information about potential adverse effects, and to avoid drug interactions.”1,10

The pharmacist is uniquely positioned in the health care system to provide assistance by implementing strategies to solve medication-related problems. In the past decade, both pharmacy education and training have changed dramatically. All pharmacy schools have changed their curricula from the traditional 5-year bachelor of science to a 6-year doctor of pharmacy (PharmD) degree. Included in the new curricula are didactic and experiential courses in pharmacology, pharmacotherapeutics, and clinical practice. These curricula emphasize patient-focused, practice-based teaching models. In the final year, students engage in both primary care and hospital-based clinical experiential training with physicians. Upon graduation, many pharmacists undergo additional residency and fellowship training. Currently, there are more than 550 pharmacy residency programs in the United States and 989 pharmacists completed a residency training program last year.11,12 Over 2900 pharmacists are certified through the Board of Pharmaceutical Specialties in various specialty areas, including pharmacotherapy, psychiatry, oncology, and nutrition support.13 Pharmacists are the most accessible health care professionals, with over 120,000 community pharmacies nation-wide.14,15 The most common pair of professionals found in rural areas is a physician and pharmacist. Additionally, many academic health centers, Veterans Affairs hospitals, and group practices utilize clinical pharmacists in direct patient care, including hypertension clinics.16,17

The ability of pharmacists to assist physicians with detection (screening), management, and control of hypertensive patients depends upon the systems of care and the degree of integration of pharmacists into the health care team.10 Achieving the above goals for hypertension treatment requires integration of health systems and health care professionals, to best achieve the goals for therapy. This paper describes current examples of pharmacy programs that assist in the management of hypertension among a variety of health care settings. We conclude with suggestions about how to incorporate pharmacy services into physicians' practices.

COMMUNITY PHARMACIES

  1. Top of page
  2. Abstract
  3. COMMUNITY PHARMACIES
  4. ACADEMIC DETAILING
  5. INTEGRATED HEALTH SYSTEMS
  6. PHYSICIAN OFFICE PRACTICES
  7. INCORPORATING PHARMACY SERVICES INTO PHYSICIANS' PRACTICES
  8. CONCLUSION
  9. References

Pharmacies are located in nearly every community.14,15 On average, patients visit a community pharmacy nearly once a month, resulting in more visits than to any other health care facility. Traditionally, community pharmacists have not been integrated within the patient care team. More recently, however, community pharmacists have begun to assist physicians with monitoring of hypertensive patients through improving medication compliance, reducing adverse reactions, and improving blood pressure control. Numerous community pharmacists screen for new or inadequately controlled hypertension and refer patients to their physicians.

It is becoming more common for some community pharmacists to develop collaborative relationships with specific physicians. These physicians often refer appropriate patients to a pharmacist for additional follow-up between physician office visits. The pharmacist may measure blood pressure, adjust dosages, and alter the antihypertensive regimen via protocols approved by the physician. In these relationships, pharmacists maintain close communication with the primary physician. One classic older study18 and three more recent studies19–21 found that blood pressure control was improved when community pharmacists assisted with patient education, blood pressure monitoring, drug therapy management, and medication adherence assessment. In two of these studies, blood pressure control, based on measurements in the physicians' offices, was improved.18,21 In addition, two studies found that quality of life improved among patients who were followed by a pharmacist for 4–6 months.20,21 The community pharmacists participating in these programs received special, comprehensive training related to hypertension and its management.

Community pharmacists can serve as an important link between the physician and patient. Despite the common perception, most patients utilize only one pharmacy. The pharmacist is often the only member of the health care team who has access to information about all of the patient's medications. Importantly, a physician may be unaware of concomitant therapies prescribed by another physician for a given patient. The physician and pharmacist can work together so that the physician's goals are achieved. The pharmacist can give the provider information on the number of prescription refills during the last year, which can be a useful surrogate for medication adherence. Physicians may use this information to make future treatment decisions. Also, pharmacists are very knowledgeable about medication costs to patients. Pharmacists can assist in the development of optimal, cost-effective strategies that utilize principles and guidelines from JNC VI1 and more recent consensus panels.5,6

ACADEMIC DETAILING

  1. Top of page
  2. Abstract
  3. COMMUNITY PHARMACIES
  4. ACADEMIC DETAILING
  5. INTEGRATED HEALTH SYSTEMS
  6. PHYSICIAN OFFICE PRACTICES
  7. INCORPORATING PHARMACY SERVICES INTO PHYSICIANS' PRACTICES
  8. CONCLUSION
  9. References

Monane and colleagues22 suggest a wide role for pharmacists in quality assurance, remediation, and improvement of medication prescribing habits. In a study from the largest pharmacy benefits manager in the United States, 12 times more modifications of potentially dangerous prescriptions were successfully implemented using a pharmacist-based, computer-assisted quality improvement program, as compared to historical controls. This program included a pharmacist-led team of professionals who interacted with the prescribing physician following a computerized quality control review of each submitted prescription. The pharmacist telephoned the physician and provided peer-to-peer counseling about proper prescribing and why the submitted prescription was of concern. The pharmacist also made suggestions that improved the probability that such errors would be unlikely to recur in the future.

Several other studies have been designed to examine pharmacists' influence on physician prescribing. To influence physician prescribing, face-to-face, academic detailing visits by pharmacists and/or physicians have been proved more effective than educational seminars, mailed educational materials, or letters to prescribers.17,23–32 However, academic detailing may not have long-lasting effects on prescribing.33 Additionally, acceptance may be limited if the person conducting the academic detailing is viewed as an outsider. To be most effective, physician education must be conducted by a person who is viewed as a colleague or opinion leader.17,34 Studies have demonstrated that physician learning often occurs from consultations with colleagues who provide knowledge that can be directly applied to specific patients during the time they are seen in the office.35–37 Consequently, we believe that the most effective strategy for improving medication prescribing is to include a pharmacist in the physician's office, clinic, or practice setting.

INTEGRATED HEALTH SYSTEMS

  1. Top of page
  2. Abstract
  3. COMMUNITY PHARMACIES
  4. ACADEMIC DETAILING
  5. INTEGRATED HEALTH SYSTEMS
  6. PHYSICIAN OFFICE PRACTICES
  7. INCORPORATING PHARMACY SERVICES INTO PHYSICIANS' PRACTICES
  8. CONCLUSION
  9. References

In fully integrated health care delivery systems, such as many Veterans Affairs medical centers (VAMCs), the Indian Health Service, and staff-model managed care organizations, clinical pharmacy specialists have multiple roles. These range from serving on the interdisciplinary primary care team and assisting physicians with optimizing drug selection and monitoring, to population-based approaches to assess adherence to treatment guidelines and the Health Plan Employer Data and Information Set (HEDIS). In integrated systems, physicians, nurses, pharmacists, dietitians, social workers, and others have access to all patient data. They communicate closely and work as true interdisciplinary teams to care for patients. In many of these settings, clinical pharmacists do not dispense medications, but instead provide direct patient care and interventions on behalf of physicians and nurses. Pharmacists in these settings serve on the Pharmacy and Therapeutics Committee and are frequently responsible for developing, adapting, and updating guidelines and treatment pathways.

At the time of this writing, approximately 31 states allow pharmacists to manage patients via collaborative practice agreements with physicians. While some such arrangements involve community pharmacists, the majority of these collaborative agreements are between physicians and pharmacists in integrated health systems. Depending on the protocol, the pharmacist may have authority to measure and assess blood pressure, initiate and adjust medication dosages, alter antihypertensive drug therapy, and perform laboratory monitoring.

A pilot study by McGhan et al.38 involved 326 patients who were assisted by pharmacists in their management of hypertension. A blinded expert panel evaluated two clinical pharmacists and three physicians. The panel rated the pharmacists significantly higher for the selection of the most appropriate drug therapy, when compared with physicians. In addition, significantly more patients in the pharmacist-managed group (97%) had controlled blood pressure, compared to the physician-managed group (78%).

Numerous settings, such as VAMCs, have developed pharmacist-managed hypertension clinics to which physicians refer patients for long-term blood pressure management and monitoring.16 In a survey of 50 VAMCs, 36 had hypertension clinics. Twenty of these 36 hypertension clinics had a clinical pharmacist who saw patients and 12 of the clinics (33%) were pharmacist-managed. In a study conducted at a VAMC, a clinical pharmacist practicing in the outpatient clinics was shown to achieve acceptable medication adherence in 72% of study group patients, compared to 20% of patients without a pharmacist (p<0.001).39 The pharmacist also reduced duplication of medications (p<0.001), cost (p<0.05), and increased documentation of drug therapy (p<0.025). In a 4-year follow-up, compliance was still 75% in the group with a clinical pharmacist.40 More importantly, baseline blood pressure control was only 29% (very similar to NHANES III data). After 9 months with the clinical pharmacist, blood pressure control significantly increased, to 69% (p<0.001), while after 4 years, blood pressure control was 90% (p<0.001 from baseline and p<0.01 from 9 months).40

The results of a multicenter, parallel, open-label pharmaceutical care outcomes study performed in 10 VAMCs and one university hospital was recently reported.41 Control patients (n=70) received usual care, while treatment patients (n=63) received special hypertension management, primarily from pharmacy residents, in addition to their usual medical care. After 6 months, there was no change in blood pressure among control patients (146/87 vs. 145/83 mm Hg), whereas in the pharmacist-treated group, there was a significant reduction in systolic blood pressure, both compared with baseline (147/85 vs. 139/80 mm Hg) and the control group (p<0.05). There was also a trend for fewer hospitalizations in the treatment group, although statistical significance was achieved only with a one-tailed p value of 0.043.

PHYSICIAN OFFICE PRACTICES

  1. Top of page
  2. Abstract
  3. COMMUNITY PHARMACIES
  4. ACADEMIC DETAILING
  5. INTEGRATED HEALTH SYSTEMS
  6. PHYSICIAN OFFICE PRACTICES
  7. INCORPORATING PHARMACY SERVICES INTO PHYSICIANS' PRACTICES
  8. CONCLUSION
  9. References

Academic health sciences centers and group practice settings have included pharmacists who either directly provided care for hypertensive patients or who made recommendations to physicians.17,42–46 One study42 compared 280 control patients and 349 experimental patients with hypertension or diabetes. Experimental patients were regularly followed by a pharmacist, while control patients were seen only by a physician. These investigators found that blood pressure control was no different in the pharmacist- and physician-managed groups. However, patients in the pharmacist-managed group had a higher kept-appointment rate and a lower drop-out rate than those in the physician-managed group (p<0.005). Medication adherence was 75% in the experimental group and 59% in the control group, but this was not a statistically significant difference.

Morse and colleagues43 reported the results of 20 patients with resistant hypertension who were provided with pharmaceutical care services. All patients attended an internal medicine clinic and had a diastolic blood pressure over 96 mm Hg while on two or more medications. A pharmacist counseled the patient about antihypertensive therapy, obtained a medication history, discussed diet, and evaluated the patient's antihypertensive regimen (based on medication adherence, adverse reactions, and regimen complexity) and possible reasons for the poor response to treatment. Then the pharmacist recommended drug therapy to the physician. At baseline, mean blood pressure, categorized as severe, moderate, or mild, was 193/124 mm Hg, 161/109 mm Hg, and 171/100 mm Hg, respectively. The average annual cost of medications was $325. After 5–8 months of pharmacist interventions, the mean blood pressure was significantly reduced from baseline among all three groups and the average annual medication cost was reduced to $143. Sixty-three percent of patients classified with severe hypertension achieved a diastolic pressure of leqslant R: less-than-or-eq, slant90 mm Hg, while 33% and 100% of patients with moderate and mild hypertension achieved a diastolic pressure of leqslant R: less-than-or-eq, slant90 mm Hg.

Erickson et al.44 evaluated 40 control patients and 40 intervention patients in a pharmacist intervention group. All patients were seen within an internal medicine clinic in a university health center and all blood pressure measurements were performed by the physician. In the intervention group, pharmacists provided education about hypertension, drug and nondrug management, and assistance to enhance medication adherence. Pharmacist recommendations were provided to physicians regarding drug therapy changes. The control group did not receive pharmacist education, and drug therapy decisions were all physician initiated. In the control group, blood pressure remained unchanged following 5 months of follow-up (154/90 vs. 151/88 mm Hg; p=0.48 for systolic and p=0.29 for diastolic). In the pharmacist intervention group, blood pressure was significantly decreased (157/92 vs. 145/87 mm Hg; p<0.01). At the end of the study, blood pressure was controlled (leqslant R: less-than-or-eq, slant140/90 mm Hg) in 30% of controls and 45% of intervention patients (p=0.17).

In a prospective, randomized, controlled study, blood pressure control among patients who received pharmacist-initiated home blood pressure monitoring significantly improved vs. control.45 All patients were seen in a family medicine clinic where the pharmacist was employed. In this study, patients randomized to the intervention group received home blood pressure monitors, a diary, and education by a pharmacist. Home blood pressure values were evaluated by a pharmacist via telephone. Consistent pressures above 140/90 mm Hg were forwarded to the family physician, along with recommendations from the pharmacist. Both systolic and diastolic pressures were significantly reduced from baseline in the intervention group (systolic, 17.0 mm Hg; diastolic, 10.5 mm Hg; p<0.0001 for both) vs. the control group (systolic, 7.0 mm Hg; diastolic, 3.8 mm Hg; p=0.12 and p=0.09, respectively). Drug therapy was changed in 83.3% of the intervention patients and only 33% of control patients (p<0.01).

In another randomized, controlled trial, 95 adult hypertensive patients who failed to meet national blood pressure goals were randomly assigned to a control arm of standard medical care or to an intervention arm in which a physician and pharmacist worked together as a team.46 Systolic blood pressure declined significantly in the intervention arm vs. the control arm (23 vs. 11 mm Hg; p<0.01). Diastolic blood pressure declined 14 and 3 mm Hg in the intervention and control arms, respectively (p<0.001). Additionally, the number of patients who achieved national blood pressure goals was significantly higher in the intervention group (55% vs. 20%; p<0.001).

INCORPORATING PHARMACY SERVICES INTO PHYSICIANS' PRACTICES

  1. Top of page
  2. Abstract
  3. COMMUNITY PHARMACIES
  4. ACADEMIC DETAILING
  5. INTEGRATED HEALTH SYSTEMS
  6. PHYSICIAN OFFICE PRACTICES
  7. INCORPORATING PHARMACY SERVICES INTO PHYSICIANS' PRACTICES
  8. CONCLUSION
  9. References

We suggest that physicians consider incorporating pharmacy services into their practices to improve blood pressure control. Many physicians' practices may not be able to fund a pharmacist working in the office. However, cost-benefit analyses for placing a clinical pharmacist in either a solo physician practice, small group practice, or larger group practice in family medicine have been performed.47–50 These studies demonstrated that it could be cost-effective for a physician practice to include a clinical pharmacist, as the long-term investment justifies the short-term cost, primarily by reducing expensive hospitalizations and other morbidity resulting from inadequately controlled hypertension.

Alternatively, physicians can contact local pharmacies to arrange collaborative management of their hypertensive patients. A group of physicians could identify a particular pharmacist who is specially trained and willing to provide these services. The pharmacy and pharmacist could be utilized for follow-up blood pressure checks. After an office visit, the physician could instruct hypertensive patients to have their blood pressure checked in 2–4 weeks at a local pharmacy known to provide high-quality services. Using the collaborative agreement, pharmacists can record patients' blood pressures and forward the results, along with a complete medication list and refill history, to the physician. Also, during the follow-up, the pharmacist can assess patients for adverse drug reactions and potential drug interactions and report them to the physician. The information can help physicians make timely decisions regarding patients' treatment regimens and adjust them accordingly.

Physicians should consider referring selected patients to a pharmacist for education about hypertension medications. The contemporary pharmacist is well trained in this area and can provide patients with valuable information that may improve medication adherence and reduce other medication-related problems. Using the collaborative agreement, the pharmacist can discuss lifestyle modification strategies with hypertensive patients and monitor their progress in conjunction with patients' medication refills. Furthermore, the pharmacist can send out monthly refill reminders to ensure medication adherence. This information can be documented and forwarded to the physician to improve blood pressure control. Importantly, the physician must have confidence that the pharmacist is willing and able to provide these services. A telephone call to the chairman of the department of pharmacy practice at a local college of pharmacy may help identify qualified health care professionals. This strategy would be much easier to implement if the Omnibus Medicare Act of 1962 were amended to include direct payment to pharmacists for such “cognitive services.”

For some group practice settings, support for a part-time or full-time pharmacist may be available. In these practices, a pharmacist could provide face-to-face patient education and medication counseling before, after, or separate from, the physician encounter. The pharmacist may be able to optimize hypertension medication use and suggest strategies to improve medication regimens for these patients. Between physician visits, specific appointments could be made to follow up with the pharmacist for blood pressure checks and continued blood pressure education. As a result, patients may view this service as an added benefit of the medical practice, since consumer confidence in pharmacists is very high. In addition, the pharmacist could be available to answer other medication-related questions by patients or providers. Based on the aforementioned studies, a pharmacist should be able to help improve blood pressure control within the practice.

Finally, we suggest involving pharmacists in the treatment decision-making process. If possible, involve the pharmacist before a prescription is written. In many organized health care delivery systems, the primary responsibility of the physician is to document the proper diagnosis. When drug therapy is involved, it is often the purview of the pharmacist to choose the correct and most cost-effective medication, dispense it and provide appropriate advice about its consumption, and monitor the patient for adverse reactions related to it. With a collaborative agreement, pharmacists can provide medication-related treatment recommendations to physicians and adjust medications according to a protocol. Data from several sources demonstrate that inclusion of pharmacists in the treatment decision can reduce medication errors and improve prescribing.51–55

CONCLUSION

  1. Top of page
  2. Abstract
  3. COMMUNITY PHARMACIES
  4. ACADEMIC DETAILING
  5. INTEGRATED HEALTH SYSTEMS
  6. PHYSICIAN OFFICE PRACTICES
  7. INCORPORATING PHARMACY SERVICES INTO PHYSICIANS' PRACTICES
  8. CONCLUSION
  9. References

The profession of pharmacy has changed significantly in recent years. This has led to innovations in which the pharmacist has become a critical interdisciplinary team member. Studies within integrated health systems have demonstrated that when pharmacists are included as members of these teams, control rates for hypertension increase. In addition, drug interactions, nonadherence, and costs can be reduced. The new Healthy People 2010 goals for hypertension require a much more intensive approach in order to achieve desired blood pressure control rates. It will be very difficult to achieve the goals for control rates in hypertensive populations without significant participation by pharmacists. It is important for health systems and group practices to include pharmacists as an integral part of the team that cares for these patients.

Acknowledgment: Portions of this review were prepared by Drs. Carter and Elliott from a section entitled “Role of the Pharmacist” that appeared in the complete and expanded internet version of the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure.

References

  1. Top of page
  2. Abstract
  3. COMMUNITY PHARMACIES
  4. ACADEMIC DETAILING
  5. INTEGRATED HEALTH SYSTEMS
  6. PHYSICIAN OFFICE PRACTICES
  7. INCORPORATING PHARMACY SERVICES INTO PHYSICIANS' PRACTICES
  8. CONCLUSION
  9. References
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