Pharmacist intervention for blood pressure control: medication intensification and adherence

Interventions and contextual factors to improve retention in care for patients with hypertension in primary care: Hermeneutic systematic review

BACKGROUND

Regular engagement over time in hypertension care, or retention, is a crucial but understudied step in optimizing patient outcomes. This systematic review leverages a hermeneutic methodology to identify, evaluate, and quantify the effects of interventions and contextual factors for improving retention for patients with hypertension.

METHODS

We searched for articles that were published between 2000 and 2022 from multiple electronic databases, including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, clinicaltrials.gov, and WHO International Trials Registry. We followed the latest version of the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline to report the findings for this review. We also synthesized the findings using a hermeneutic methodology for systematic reviews, which used an iterative process to review, integrate, analyze, and interpret evidence.

RESULTS

From 4686 screened titles and abstracts, 18 unique studies from 9 countries were identified, including 10 (56%) randomized controlled trials (RCTs), 3 (17%) cluster RCTs, and 5 (28%) non-RCT studies. The number of participants ranged from 76 to 1562. The overall mean age range was 41-67 years, and the proportion of female participants ranged from 0% to 100%. Most (n = 17, 94%) studies used non-physician personnel to implement the proposed interventions. Fourteen studies (78%) implemented multilevel combinations of interventions. Education and training, team-based care, consultation, and Short Message Service reminders were the most common interventions tested.

CONCLUSIONS

This review presents the most comprehensive findings on retention in hypertension care to date and fills the gaps in the literature, including the effectiveness of interventions, their components, and contextual factors. Adaptation of and implementing HIV care models, such differentiated service delivery, may be more effective and merit further study.

REGISTRATION

CRD42021291368.

PROTOCOL REGISTRATION

PROSPERO 2021 CRD42021291368. Available at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=291368.

Comparative Different Interventions to Improve Medication Adherence in Patients with Hypertension: A Network Meta-analysis

BACKGROUND

Hypertension has become a major public problem. One of every 4 adults has hypertension. Medications are critical in controlling blood pressure, but patient medication adherence is low. Therefore, it is very crucial to promote medication adherence. However, the complexity and variety of interventions cause clinical decision-making difficulties for health managers and patients.

OBJECTIVE

The aim of this study was to compare the effectiveness of different interventions to improve medication adherence in patients with hypertension.

METHODS

We searched PubMed, Cochrane Library, Web of Science, EMBASE, Wan Fang, China National Knowledge Infrastructure, China Science and Technology Journal Database, and China Biology Medicine disc databases for eligible studies. Medication adherence rate and medication adherence difference were assessed as outcomes. Sensitivity analysis and inconsistency detection were performed to evaluate whether the exclusion of high-risk studies affected the validity. The risk of bias was assessed using the risk of bias table in Review Manager 5.4. The surface under the cumulative ranking curve was used to estimate the rankings among different interventions.

RESULTS

Twenty-seven randomized controlled trials were included, and the interventions involved were categorized into 8 different categories. The network meta-analysis showed that the health intervention was the best to promote medication compliance in patients with hypertension.

CONCLUSIONS

Health intervention is recommended to improve medication adherence in patients with hypertension.

CLINICAL IMPLICATIONS

Health managers are recommended to provide health intervention to patients with hypertension to improve their medication adherence. This approach reduces morbidity, mortality, and healthcare costs for patients with cardiovascular disease.

Centrally supported clinical pharmacist intervention to reduce clinical inertia in hypertension

PURPOSE

To assess the impact of a one-time hypertension (HTN)-focused clinical pharmacist intervention on the occurrence of clinical inertia and change in blood pressure (BP).

METHODS

This retrospective study included patients 18 to 89 years of age with a current diagnosis of HTN and average systolic BP of ≥150 mm Hg. Centralized outreach coordinators performed telephone outreach to patients to schedule an HTN-focused visit with their primary care provider (PCP) and forwarded outreach notes for half of these patients to clinical pharmacists embedded in an internal medicine clinic. The clinical pharmacists performed a one-time focused medication review and provided evidence-based recommendations to a patient's PCP prior to the scheduled appointment. The primary outcome was therapy intensification (medication adjustment or adherence discussion) as a measure of overcoming clinical inertia. Secondary outcomes were the mean changes in systolic and diastolic BP from preintervention values to 6-month follow-up in the intervention group versus the control group.

RESULTS

A total of 91 patients were included, and 34 of 47 intervention patients (72%) had therapy intensification at the HTN-focused PCP appointment, compared to 20 of 44 control patients (46%) (P =0.017). The mean (SD) systolic BP reductions from baseline were 12.26 (29.04) mm Hg and 6.97 (27.05) mm Hg for the intervention and control groups, respectively (P =0.427), with diastolic BP reductions of 3.83 (13.14) mm Hg and 1.35 (10.60) mm Hg, respectively (P =0.380).

CONCLUSION

A collaborative model involving centralized outreach coordinators and embedded clinical pharmacists led to a significant reduction in clinical inertia. This was a small-scale pilot study, and further research is needed to determine the effect of this intervention on BP reduction.

A narrative review: Pharmacy intervention fidelity

BACKGROUND

There has been a significant increase in the literature surrounding community-based pharmacy interventions. However, less is known about how researchers assured these interventions were implemented consistently and faithfully to the established protocol.

OBJECTIVE

This narrative review aims to describe the nature and extent to which researchers reported intervention fidelity measures across depression and hypertension studies completed in community and ambulatory care settings.

METHODS

Two research assistants used defined literature search criteria to identify manuscripts involving community pharmacist interventions in hypertension or depression care management. These research assistants independently evaluated each manuscript based on the nature and extent to which the studies described intervention training to support intervention fidelity, the intervention structure and content, the tools used to document intervention fidelity, and the extent to which the intervention was performed as expected. Manuscript authors were contacted for clarification of any details not clear from their published works.

RESULTS

Of the 6 depression and 19 hypertension manuscripts, intervention training was described in only 2 and 9 depression and hypertension manuscripts, respectively. Other depression and hypertension manuscripts did not describe such training or gave unclear training information. Respectively, only 2 and 9 of the depression and hypertension manuscripts described a tool that was used to capture interventions made according to protocol. Two of the depression manuscripts and 6 of the hypertension manuscripts were known to have measured the extent to which the intervention was performed as expected.

CONCLUSION

There is considerable variability in the nature and extent that intervention fidelity measures are reported in the literature. Researchers should be required to report key intervention fidelity measures when seeking publication of their research. Such additional reporting of fidelity results will enable the scientific community to have greater confidence in study results, conclusions, and implications.

Evaluation of a Pharmacists' Patient Care Process Approach for Hypertension

INTRODUCTION

An estimated 116 million American adults (47.3%) have hypertension. Most adults with hypertension do not have it controlled-3 in 4 (92.1 million) U.S. adults with hypertension have a blood pressure ≥130/80 mmHg. The Pharmacists' Patient Care Process is a standardized patient-centered approach to the provision of pharmacist care that is done in collaboration with other healthcare providers. Through the Michigan Medicine Hypertension Pharmacists' Program, pharmacists use the Pharmacists' Patient Care Process to provide hypertension management services in collaboration with physicians in primary care and community pharmacy settings. In 2019, the impact of Michigan Medicine Hypertension Pharmacists' Program patient participation on blood pressure control was evaluated.

METHODS

Propensity scoring was used to match patients in the intervention group with patients in the comparison group and regression analyses were then conducted to compare the 2 groups on key patient outcomes. Negative binomial regression was used to examine the number of days with blood pressure under control. The findings presented in this brief are part of a larger multimethod evaluation.

RESULTS

More patients in the intervention group than in the comparison group achieved blood pressure control at 3 months (66.3% vs 42.4%) and 6 months (69.1% vs 56.5%). The intervention group experienced more days with blood pressure under control within a 3-month (18.6 vs 9.5 days) and 6-month period (57.0 vs 37.4 days) than the comparison group did.

CONCLUSIONS

Findings support the effectiveness of the Michigan Medicine Hypertension Pharmacists' Program approach to implementing the Pharmacists' Patient Care Process to improve blood pressure control.

Implementation of Outpatient Pharmacist-led Hypertension Management for Under-Resourced Patients: A Pilot Study

Background:

The purpose of this study was to implement and evaluate a pharmacist-led hypertension (HTN) program for under-resourced patients discharged from the emergency department (ED) or screened at community health events who are lacking a regular primary care provider (PCP) relationship.

Methods:

This was a single arm, prospective, pilot study to recruit patients from the Detroit Medical Center (DMC) Sinai Grace Hospital (SGH) ED and community health events. The outpatient pharmacist-led transitional care clinic (TCC) was implemented through a collaborative practice agreement (CPA) with ED physicians. Eligible patients 18 to 60 years with elevated blood pressure (BP) (> 140/90 mmHg) and lacking a PCP relationship were referred to the TCC for HTN management. The primary outcome measure was change in systolic and diastolic BP (SBP and DBP). Difference in BP values was evaluated using Wilcoxon Signed Ranks test and descriptive statistics were used to explain demographic data.

Results:

There were 116 patients enrolled May 2017 to August 2018; 44 (37.9%) completed visit one [cohort 1], 30 (25.9%) completed at least three visits [cohort 2], and 16 (13.8%) completed five visits [cohort 3]. Most patients were African American (AA) 97.7%, 47.8% were male, and an average of 42.11 (SD 9.70) years. For cohorts 2 and 3, there was significant reduction in BP between TCC visits one and two and the reduction was maintained through five visits for patients that remained in the study. Patients who completed five visits (n=16) showed a significant change from visit one to visit five in SBP of -23 mmHg (p=0.002) and achieved BP goal with an average SBP 139 mmHg (SD 19.33) and DBP 90 mmHg (SD 10.17).

Conclusion:

The pharmacist-led TCC was successfully implemented. Outpatient pharmacists collaborating with ED physicians increased access to HTN management with a positive impact on BP outcomes in an under-resourced population.

Evaluation of clinical pharmacist interventions for adverse events in hospitalized patients with thoracic cancer receiving cancer chemotherapy

Due to the increasing complexity of cancer chemotherapy and its associated supportive care, the role of clinical pharmacists in cancer chemotherapy is becoming increasingly more important. The present study evaluated the clinical interventions of a single pharmacist on the adverse events in hospitalized patients with thoracic cancer receiving cancer chemotherapy. A single-center, retrospective study was conducted at the 614-bed, tertiary care Gifu University Hospital. Hospitalized patients with thoracic cancer who received cancer chemotherapy in the respiratory medicine ward between April 2013 and May 2014 were enrolled. One of the two clinical pharmacists in charge was based in the respiratory medicine ward and implemented pharmaceutical care for the patients, including management of adverse events. Patient data were recorded in the electronic medical chart and retrospectively analyzed. A total of 445 patients with thoracic cancer received cancer chemotherapy in the respiratory medicine ward. A total of 152 interventions (101 patients) were performed by the clinical pharmacist prior to the administration of cancer chemotherapy, half of which comprised the addition of drugs to prevent adverse events. A total of 190 patients (39.4%) experienced grade ≥2 non-hematological or grade ≥3 hematological adverse events associated with cancer chemotherapy, and 223 medical interventions for relief of adverse events lowered the incidence of grade ≥2 non-hematological or grade ≥3 hematological adverse events to 17.8%. Of these, 45.3 and 7.5% of medical interventions for non-hematological and hematological adverse events, respectively, were implemented based on the pharmacist's recommendations. These findings revealed the marked contribution of a single clinical pharmacist in the respiratory medicine ward to the prevention and relief of adverse events in hospitalized patients with thoracic cancer receiving cancer chemotherapy.

Primary care pharmacy technicians: Effect on pharmacist workload and patient access to clinical pharmacy services

PURPOSE

Improve patient access to clinical pharmacy services and decrease pharmacist technical task workload in primary care (PC) clinics.

SUMMARY

Due to concerns with the amount of technical tasks performed by University of Wisconsin Health PC clinical pharmacists negatively impacting their capacity to care for patients and perform clinical tasks, the pharmacy department piloted a new PC pharmacy technician role that involved completion of technical tasks previously performed by PC pharmacists. PC pharmacist daily technical and clinical activities were identified through shadowing and quantified by a 4-week period of work sampling. A PC pharmacist workgroup determined the technical tasks that would be appropriate for a pharmacy technician to complete and developed the technician workflows. A PC pharmacy technician was implemented during a 3-week pilot, when pharmacist daily technical and clinical activities were quantified through work sampling. Following implementation, a 52.7% (P < 0.001) relative reduction and a 10.2% (P < 0.001) relative increase in pharmacist technical and clinical activities, respectively, were identified. Additionally, a 10% relative increase from the previous 3-month average was observed in the PC pharmacist rolling patient panel size during the pilot period, correlating with an increase of patient access to pharmacist clinical services.

CONCLUSION

Up to 17% of PC pharmacist daily activities are technical tasks. Leveraging pharmacy technicians to support pharmacists with completion of these tasks increases patient access to clinical pharmacy services but requires additional staff resources.

Impact of Pharmacist-Led Interventions on Medication Adherence and Clinical Outcomes in Patients with Hypertension and Hyperlipidemia: A Scoping Review of Published Literature

BACKGROUND

The aim of this study was to provide a scoping review of the impact of pharmacist-led interventions on medication adherence and clinical outcomes in patients with hypertension and hyperlipidemia.

METHODS

A scoping review was conducted using pre-defined search terms in three scientific databases, including Google Scholar, ScienceDirect, and PubMed. A multi-stage screening process that considered relevancy, publication year (2009-2019), English language, and article type (original research) was followed. Review articles, meta-analysis studies, and conference proceedings were excluded. Data charting was done in an iterative process using a study-specific extraction form.

RESULTS

Of the initially identified 681 studies, 17 studies with 136,026 patients were included in the review. Of these, 16 were randomized controlled trials, while the remaining study was a retrospective cohort study. The majority of pharmacist-led interventions were face-to-face counseling sessions (n=8), followed by remote- or telephone-based interventions (n=5) and multi-faceted interventions (n=4). The majority of the studies (n=7) used self-reported adherence measures and pharmacy refill records (n=8) to measure the rate of adherence to prescribed medications. Eleven of the included studies reported a statistically significant (P<0.05) impact on medication adherence. Overall, twelve studies assessed the effect of the interventions on the clinical outcome measures; of these, only four studies were associated with significant impact.

CONCLUSION

Pharmacist-led interventions were associated with improved patients' adherence to their medications but were less likely to be consistently associated with the attainment of clinical outcomes. Face-to-face counseling was the most commonly used intervention; while, the multi-faceted interventions were more likely to be effective in improving the overall outcome measures. The rigorous design of targeted interventions with more frequent follow-ups, careful consideration of the involved medications, and patients' characteristics could increase the effectiveness of these interventions.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

Architecting Process of Care: A randomized controlled study evaluating the impact of providing nonadherence information and pharmacist assistance to physicians

OBJECTIVE

To test the impact of connecting physicians, pharmacists, and patients to address medication nonadherence, and to compare different physician choice architectures.

DATA SOURCES AND STUDY SETTING

The study was conducted with 90 physicians and 2602 of their patients on medications treating chronic illness.

STUDY DESIGN

In this cluster randomized controlled trial, physicians were randomly assigned to an arm where the physician receives notification of patient nonadherence derived from real-time claims data, an arm where they receive this information and a pharmacist may contact patients either by default or by physician choice, and a control group. The primary outcome was resolving nonadherence within 30 days. We also considered physician engagement outcomes including viewing information about nonadherence and utilizing a pharmacist.

DATA COLLECTION

Physician engagement was constructed from metadata from the study website; adherence outcomes were constructed from medication claims.

PRINCIPAL FINDINGS

We see no differences between the treatment arms and control for the primary adherence outcome. The pharmacist intervention was 42 percentage points (95% CI: 28 pp-56 pp) more likely when it was triggered by default.

CONCLUSIONS

Access to a pharmacist and real-time nonadherence information did not improve patient adherence. Physician process of care was sensitive to choice architecture.

Do randomised controlled trials relevant to pharmacy meet best practice standards for quality conduct and reporting? A systematic review

OBJECTIVES

Evidence-based pharmacy practice requires a dependable evidence base. Randomised controlled trials (RCTs) are the gold standard of high-quality primary research, and tools exist to assist researchers in conducting and reporting high-quality RCTs. This review aimed to explore whether RCTs relevant to pharmacy are conducted and reported in line with Cochrane risk of bias and CONSORT standards, respectively.

METHODS

A MEDLINE search identified potential papers. After screening of titles, abstracts and full texts, the 50 most recent papers were reviewed and assessment of bias according to Cochrane domains and compliance with CONSORT checklist items was recorded. Each domain of the Cochrane tool and CONSORT checklist item and each article were given a percentage score, reported as median and interquartile range (IQR). Correlation between quality of conduct, quality of reporting, continent of origin, and journal impact factor was conducted using the R² statistic. The median domain score for risk of bias by paper according to the Cochrane risk of bias tool was 53.0% (IQR 38.5-68.5), while the median compliance score by paper for the CONSORT checklist was 64.0% (IQR 36.0-94.0%).

KEY FINDINGS

The median Cochrane domain and median CONSORT item completion scores, respectively, were 50.0% (IQR 33.3-66.7%) and 59.5% (IQR 52.0-70.3%). The highest risk of bias was associated with allocation concealment and blinding, and the least well-reported items were randomisation details, sequence generation and allocation concealment. A positive relationship between conduct and reporting of RCTs was found (R²  = 0.75), while no correlation was found between quality of conduct or quality of reporting and journal impact factor, correlation coefficients (R²  = 0.06 and R²  = 0.05, respectively).

SUMMARY

This review identified that issues related to randomisation and blinding are often inadequately conducted or not comprehensively reported by researchers conducting pharmacy relevant RCTs, providing useful information for education and future research.

Cluster-Randomized Trial to Evaluate a Centralized Clinical Pharmacy Service in Private Family Medicine Offices

BACKGROUND

The use of clinical pharmacists in primary care has improved the control of several chronic cardiovascular conditions. However, many private physician practices lack the resources to implement team-based care with pharmacists. The purpose of this study was to evaluate whether a centralized, remote, clinical pharmacy service could improve guideline adherence and secondary measures of cardiovascular risk in primary care offices in rural and small communities.

METHODS AND RESULTS

This study was a prospective trial in 12 family medicine offices cluster randomized to either the intervention or usual care. The intervention was delivered for 12 months, and subjects had research visits at baseline and 12 months. The primary outcome was adherence to guidelines, and secondary outcomes included changes in key cardiovascular risk factors and preventative health measures. We enrolled 302 subjects. There was no improvement in the Guideline Advantage score from baseline to 12 months in the control group (64.7% versus 63.1%, respectively; P=0.21). There was a statistically significant improvement in the intervention group from 63.3% at baseline to 67.8% at 12 months (P=0.02). The estimated benefit of the intervention was 5.0%±2.4% (95% confidence interval=-0.5% to 10.4%; P=0.07). Several criteria were significantly better for intervention subjects, including appropriate statin therapy (P<0.001), body mass index, screening (P<0.001), and alcohol screening (P<0.001). Only 13.7% of subjects with diabetes mellitus had hemoglobin A1c at goal at baseline, and this increased to 30.8% and 21.0% in the intervention and control group, respectively, at 12 months (P=0.10).

CONCLUSIONS

The centralized, remote pharmacist intervention was successfully implemented. The improvements in outcomes were modest, in part because of higher than expected baseline guideline adherence. Future studies of this model should focus on patients with uncontrolled conditions at high risk for cardiovascular events.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT 01983813.

The role of the pharmacist in hypertension management

PURPOSE OF REVIEW

Hypertension remains a vital, modifiable risk factor in the prevention of cardiovascular disease. However, many patients do not achieve their therapeutic goals for numerous reasons which can include poor disease insight and nonadherence. Pharmacists can be key players in controlling hypertension, given their medication knowledge and patient counseling skills, yet they remain an underutilized resource in the management of chronic disease states. Various models exist that allow pharmacists to provide direct patient-centered care but practices differ from state to state since pharmacists are not recognized nationally as healthcare providers. This article aims to provide an update on the proven methods in which pharmacists contribute to the management of hypertensive patients.

RECENT FINDINGS

Several recently published studies demonstrate the positive impact of pharmacist intervention and care on patient outcomes in ambulatory and community settings. These practice models include medication therapy management, collaborative drug therapy management, telehealth and team-based care.

SUMMARY

The role of the pharmacist in hypertension encompasses medication management, disease state education and patient counseling and is most successful when integrated into the patient's care team. Further validation through larger, prospective trials and evaluation of long-term outcomes, such as mortality, remain viable research opportunities.

A retrospective analysis of patient care activities in a community pharmacy mental illness and addictions program

BACKGROUND

The Bloom Program, a community pharmacy-based mental health and addictions care program, was developed and implemented to optimize pharmacists' care of eligible patients. Characterizing pharmacists' activities in the Bloom Program can facilitate program quality improvement and contribute more broadly to the knowledge base regarding pharmacists' roles and contributions to patient care.

OBJECTIVES

To characterize the patient care activities of the pharmacists in the Bloom Program.

METHODS

A retrospective analysis of patient charts for participants enrolled in the program for three months or longer was conducted. Using all available documentation, pharmacists' activities were coded into eight non-mutually exclusive categories: navigation/resource support, urgent triage, medication management, collaboration/communication, education, social support, self-care, and other.

RESULTS

2055 activities from 1144 patient care encounters were identified for 126 participants (48 ± 16 years of age, 61% female, 5 regular medications). Medication management was coded most often per encounter (73%). Each of social support, collaboration/communication, and education were coded in 20-25% of encounters. Frequency of navigation/resources, self-care, and urgent triage were 16.6%, 13.5%, and 2.8%, respectively. Non-medication management activities represented 59.4% of all pharmacist patient care services.

CONCLUSIONS

Medication management activities were coded in over 70% of patient encounters for pharmacists delivering a community pharmacy-based mental illness and addictions program. However, this accounted for 40.6% of activities with an average of 1.8 activities per encounter. Other activities were identified frequently (e.g., education, collaboration, social support, navigation and resource support) and help to characterize the nature of pharmacist-patient encounters and facilitates a better understanding of the role of the pharmacist in mental illness and addictions patient care.

Pharmacist Intervention for Blood Pressure Control in Patients with Diabetes and/or Chronic Kidney Disease

OBJECTIVES

The objectives of this study were to determine if hypertensive patients with comorbid diabetes mellitus (DM) and/or chronic kidney disease (CKD) receiving a pharmacist intervention had a greater reduction in mean blood pressure (BP) and improved BP control at 9 months compared with those receiving usual care; and compare Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guideline and 2014 guideline (JNC 8) BP control rates in patients with DM and/or CKD.

METHODS

This cluster randomized trial included 32 medical offices in 15 states. Clinical pharmacists made treatment recommendations to physicians at intervention sites. This post hoc analysis evaluated mean BP and BP control rates in the intervention and control groups.

MAIN RESULTS

The study included 335 patients (227 intervention, 108 control) when mean BP and control rates were evaluated by JNC 7 inclusion and control criteria. When JNC 8 inclusion and control criteria were applied, 241 patients (165 intervention, 76 control) remained and were included in the analysis. The pharmacist-intervention group had significantly greater mean systolic blood pressure reduction compared with usual care at 9 months (8.64 mm Hg; 95% confidence interval [CI] -12.8 to -4.49, p<0.001). The pharmacist-intervention group had significantly higher BP control at 9 months than usual care by either the JNC 7 or JNC 8 inclusion and control groups (adjusted odds ratio [OR] 1.97, 95% CI 1.01-3.86, p=0.0470 and OR 2.16, 95% CI 1.21-3.85, p=0.0102, respectively).

PRINCIPAL CONCLUSIONS

This study demonstrated that a physician-pharmacist collaborative intervention was effective in reducing mean systolic BP and improving BP control in patients with uncontrolled hypertension with DM and/or CKD, regardless of which BP guidelines were used.

Team-Based Care with Pharmacists to Improve Blood Pressure: a Review of Recent Literature

PURPOSE OF REVIEW

We review studies published since 2014 that examined team-based care strategies and involved pharmacists to improve blood pressure (BP). We then discuss opportunities and challenges to sustainment of team-based care models in primary care clinics.

RECENT FINDINGS

Multiple studies presented in this review have demonstrated that team-based care including pharmacists can improve BP management. Studies highlighted the cost-effectiveness of a team-based pharmacy intervention for BP control in primary care clinics. Little information was found on factors influencing sustainability of team-based care interventions to improve BP control. Future work is needed to determine the best populations to target with team-based BP programs and how to implement team-based approaches utilizing pharmacists in diverse clinical settings. Future studies need to not only identify unmet clinical needs but also address reimbursement issues and stakeholder engagement that may impact sustainment of team-based care interventions.

Polypill, hypertension and medication adherence: The solution strategy?

INTRODUCTION

Hypertension is an important global health challenge and a leading preventable risk factor for premature death and disability worldwide. In current cardiology practice, the main obstacles in the management of patients affected by hypertension are comorbidities and poor adherence to pharmacological treatments. The World Health Organization has recently highlighted increased adherence as a key development need for reducing cardiovascular disease.

METHODS

Principal observational and clinical trial data regarding adherence, reductions in cardiovascular risk and safety of the polypill approach are summarized and reviewed.

CONCLUSIONS

The polypill approach has been conclusively shown to increase adherence relative to usual care in all cardiovascular patients, furthermore, concomitant risk factor reductions have also been suggested. To date, the use of polypill could represent a solution strategy in patients affected by hypertension, comorbidities and non-adherence even though further studies, especially in the real-world settings, are needed in order to better understand its role in clinical practice.

Incorporating Patients' Social Determinants of Health into Hypertension and Depression Care: A Pilot Randomized Controlled Trial

The objective of this study was to carry out a randomized controlled pilot trial to test the effectiveness of an integrated intervention for hypertension and depression incorporating patients' social determinants of health (enhanced intervention) versus an integrated intervention alone (basic intervention). In all, 54 patients were randomized. An electronic monitor was used to measure blood pressure, and the nine-item Patient Health Questionnaire (PHQ-9) assessed depressive symptoms. Patients in the enhanced intervention had a significantly improved PHQ-9 mean change from baseline in comparison with patients in the basic intervention group at 12 weeks (p = 0.024). Patients in the enhanced intervention had a significantly improved systolic and diastolic blood pressure mean change from baseline in comparison with patients in the basic intervention group at 12 weeks (p = 0.003 and p = 0.019, respectively). Our pilot trial results indicate integrated care management that addresses the social determinants of health for patients with hypertension and depression may be effective.

The degree of integration of non-dispensing pharmacists in primary care practice and the impact on health outcomes: A systematic review

BACKGROUND

A non-dispensing pharmacist conducts clinical pharmacy services aimed at optimizing patients individual pharmacotherapy. Embedding a non-dispensing pharmacist in primary care practice enables collaboration, probably enhancing patient care. The degree of integration of non-dispensing pharmacists into multidisciplinary health care teams varies strongly between settings. The degree of integration may be a determinant for its success.

OBJECTIVES

This study investigates how the degree of integration of a non-dispensing pharmacist impacts medication related health outcomes in primary care.

METHODS

In this literature review we searched two electronic databases and the reference list of published literature reviews for studies about clinical pharmacy services performed by non-dispensing pharmacists physically co-located in primary care practice. We assessed the degree of integration via key dimensions of integration based on the conceptual framework of Walshe and Smith. We included English language studies of any design that had a control group or baseline comparison published from 1966 to June 2016. Descriptive statistics were used to correlate the degree of integration to health outcomes. The analysis was stratified for disease-specific and patient-centered clinical pharmacy services.

RESULTS

Eighty-nine health outcomes in 60 comparative studies contributed to the analysis. The accumulated evidence from these studies shows no impact of the degree of integration of non-dispensing pharmacists on health outcomes. For disease specific clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 75%, 63% and 59%. For patient-centered clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 55%, 57% and 70%.

CONCLUSIONS

Full integration adds value to patient-centered clinical pharmacy services, but not to disease-specific clinical pharmacy services. To obtain maximum benefits of clinical pharmacy services for patients with multiple medications and comorbidities, full integration of non-dispensing pharmacists should be promoted.

Primary Care Physician-Pharmacist Collaborative Care Model: Strategies for Implementation

The Collaboration Among Pharmacists and Physicians To Improve Outcomes Now (CAPTION) trial recently found that a pharmacist intervention for hypertension could be implemented in diverse medical offices. In this issue of Pharmacotherapy, the article by Brian Isetts and colleagues discusses the complexity of the patient population, the specific functions the pharmacists performed, and the time estimates from billing records used to quantify time spent during face-to-face patient encounters. This invited commentary will discuss findings from the CAPTION trial and provide recommendations for strategies to implement similar interventions for patients with other chronic medical conditions seen in primary care practices.

Evaluation of Pharmacists' Work in a Physician-Pharmacist Collaborative Model for the Management of Hypertension

STUDY OBJECTIVE

Physician-pharmacist collaborative models have been shown to improve the care of patients with numerous chronic medical conditions. Team-based health care using integrated clinical pharmacists provides one opportunity to improve quality in health care systems that use population-based financing. In November 2015, the Centers for Medicare and Medicaid Services (CMS) requested that the relative value of pharmacists' work in team-based care needs to be established. Thus the objective of this study was to describe the components of pharmacists' work in the management of hypertension with a physician-pharmacist collaborative model.

DESIGN

Descriptive analysis of the components of pharmacists' work in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now (CAPTION) study, a prospective, cluster randomized trial.

MEASUREMENTS AND MAIN RESULTS

This analysis was intended to provide policymakers with data and information, using the CAPTION study model, on the time and intensity of pharmacists' work to understand pharmacists' relative value contributions in the context of CMS financing and population management aims. The CAPTION trial was conducted in 32 community-based medical offices in 15 U.S. states and included 390 patients with multiple cardiovascular risk factors. Blood pressure was measured by trained study coordinators in each office, and patients were included in the study if they had uncontrolled blood pressure. Included patients were randomized to a 9-month intervention, a 24-month intervention, or usual care. The goal of the pharmacist intervention was to improve blood pressure control and resolve drug therapy problems impeding progress toward blood pressure goals. This intervention included medical record review, a structured assessment with the patient, collaboration to achieve goals of therapy, and patient follow-up. The two intervention arms (9 and 24 mo) were identical the first 9 months, and that time frame is the focus of this workload evaluation. Pharmacists completed study encounter forms for every patient encounter and estimated time spent in pre-visit, face-to-face care, and post-visit activities. Among the 390 patients, there were 2811 encounters with pharmacists that involved 3.44 hours/patient for face-to-face care visits plus 1.55 hours/patient for pre-visit and post-visit work. Intensity of work was reflected in interventions to resolve drug therapy problems with patients (43% of encounters) and with physicians (1169 recommendations, of which physicians accepted 1153 [98.6%]), resulting in improvement of patients' blood pressure goals achieved (from 0% at baseline to 43% at 9 months based on the primary study end point).

CONCLUSION

Pharmacists provided extensive interventions to patients with hypertension. This analysis provides a framework for health systems, provider groups, and payers to measure pharmacists' work in value-based financing and population management.

Physician-pharmacist collaboration versus usual care for treatment-resistant hypertension

Team-based care has been recommended for patients with treatment-resistant hypertension (TRH), but its efficacy in this setting is unknown. We compared a physician-pharmacist collaborative model (PPCM) to usual care in patients with TRH participating in the Collaboration Among Pharmacists and Physicians To Improve Outcomes Now study. At baseline, 169 patients (27% of Collaboration Among Pharmacists and Physicians To Improve Outcomes Now patients) had TRH: 111 received the PPCM intervention and 58 received usual care. Baseline characteristics were similar between treatment arms. After 9 months, adjusted mean systolic blood pressure was reduced by 7 mm Hg more with PPCM intervention than usual care (P = .036). Blood pressure control was 34.2% with PPCM versus 25.9% with usual care (adjusted odds ratio, 1.92; 95% confidence interval, 0.33-11.2). These findings suggest that team-based care in the primary care setting may be effective for TRH. Additional research is needed regarding the long-term impact of these models and to identify patients most likely to benefit from team-based interventions.

Cost-Effectiveness of a Physician-Pharmacist Collaboration Intervention to Improve Blood Pressure Control

Previous studies have demonstrated the cost-effectiveness of physician-pharmacist collaborations to improve hypertension control. However, most studies have limited generalizability, lacking minority and low-income populations. The Collaboration Among Pharmacist and Physicians to Improve Blood Pressure Now (CAPTION) trial randomized 625 patients from 32 medical offices in 15 states. Each office had an existing clinical pharmacist on staff. Pharmacists in intervention offices communicated with patients and made recommendations to physicians about changes in therapy. Demographic information, blood pressure (BP), medications, and physician visits were recorded. In addition, pharmacists tracked time spent with each patient. Costs were assigned to medications and pharmacist and physician time. Cost-effectiveness ratios were calculated based on changes in BP measurements and hypertension control rates. Thirty-eight percent of patients were black, 14% were Hispanic, and 49% had annual income <$25 000. At 9 months, average systolic BP was 6.1 mm Hg lower (±3.5), diastolic was 2.9 mm Hg lower (±1.9), and the percentage of patients with controlled hypertension was 43% in the intervention group and 34% in the control group. Total costs for the intervention group were $1462.87 (±132.51) and $1259.94 (±183.30) for the control group, a difference of $202.93. The cost to lower BP by 1 mm Hg was $33.27 for systolic BP and $69.98 for diastolic BP. The cost to increase the rate of hypertension control by 1 percentage point in the study population was $22.55. Our results highlight the cost-effectiveness of a clinical pharmacy intervention for hypertension control in primary care settings.