Improving blood pressure control through pharmacist interventions: a meta-analysis of randomized controlled trials

Stroke Risk Reduction in Atrial Fibrillation Through Pharmacist Prescribing: A Randomized Clinical Trial

Importance

Major gaps in the delivery of appropriate oral anticoagulation therapy (OAC) exist, leaving a large proportion of persons with atrial fibrillation (AF) unnecessarily at risk for stroke and its sequalae.

Objective

To investigate whether pharmacist-led OAC prescription can increase the delivery of stroke risk reduction therapy in individuals with AF.

Design, Setting, and Participants

This prospective, open-label, patient-level randomized clinical trial of early vs delayed pharmacist intervention from January 1, 2019, to December 31, 2022, was performed in 27 community pharmacies in Alberta, Canada. Pharmacists identified patients 65 years or older with 1 additional stroke risk factor and known, untreated AF (OAC nonprescription or OAC suboptimal dosing) or performed screening using a 30-second single-lead electrocardiogram to detect previously unrecognized AF. Patients with undertreated or newly diagnosed AF eligible for OAC therapy were considered to have actionable AF. Data were analyzed from April 3 to November 30, 2023.

Interventions

In the early intervention group, pharmacists prescribed OAC using guideline-based algorithms with follow-up visits at 1 and 3 months. In the delayed intervention group, which served as the usual care control, the primary care physician (PCP) was sent a notification of actionable AF along with a medication list (both enhancement over usual care). After 3 months, patients without OAC optimization in the control group underwent delayed pharmacist intervention.

Main Outcomes and Measures

The primary outcome was the difference in the rate of guideline-concordant OAC use in the 2 groups at 3-month follow-up ascertained by a research pharmacist blinded to treatment allocation.

Results

Eighty patients were enrolled with actionable AF (9 [11.3%] newly diagnosed in 235 individuals screened). The mean (SD) age was 79.7 (7.4) years, and 45 patients (56.3%) were female. The median CHADS2 (congestive heart failure, hypertension, age, diabetes, and stroke or transient ischemic attack) score was 2 (IQR, 2-3). Seventy patients completed follow-up. Guideline-concordant OAC use at 3 months occurred in 36 of 39 patients (92.3%) in the early intervention group vs 23 of 41 (56.1%) in the control group (P < .001), with an absolute increase of 34% and number needed to treat of 3. Of the 23 patients who received appropriate OAC prescription in the control group, the PCP called the pharmacist for prescribing advice in 6 patients.

Conclusions and Relevance

This randomized clinical trial found that pharmacist OAC prescription is a potentially high-yield opportunity to effectively close gaps in the delivery of stroke risk reduction therapy for AF. Scalability and sustainability of pharmacist OAC prescription will require larger trials demonstrating effectiveness and safety.

Trial Registration

ClinicalTrials.gov Identifier: NCT03126214.

Considering the Possible Role of Pharmacists According to the Presence or Absence of Lifestyle-Related Diseases at the Time of Coronary CT Examination and Trends of Medication Use for These Diseases by Medical Doctors

BACKGROUND

Because patients often already have coronary artery disease (CAD) at the time of a coronary artery computed tomography angiography (CCTA) examination, we examined the medications prescribed by medical doctors for lifestyle-related diseases and investigated what possible role pharmacists can play in prescribing.

METHODS

Patients (n = 1357) who underwent CCTA examination were divided into two groups according to the presence or absence of lifestyle-related diseases [hypertension (HTN), dyslipidemia (DL) and diabetes mellitus (DM)], and the relationship between the presence or absence of CAD was examined.

RESULTS

The rate of CAD was significantly higher in patients with HTN, DL or DM than in patients without these diseases. The blood pressure in the HTN group was 140 ± 20/79 ± 13 mmHg, the low-density lipoprotein cholesterol value in the DL group was 119 ± 35 mg/dL, and the hemoglobin A1c value in the DM group was 7.0 ± 1.1%, all of which were poorly controlled. Anti-hypertensive drugs were used at low rates in the HTN group, statins were used in 47% and ezetimibe was used in 4% of the DL group, and dipeptidyl peptidase-4 inhibitors were used in 41% of the DM group.

CONCLUSIONS

Since the rate of CAD (+) was high and control of the three major lifestyle-related diseases was poor, pharmacists should advise medical doctors to use combinations of drugs.

Strategies for improving the treatment and control of hypertension in Japan

Despite the significant advancements in the diagnosis and treatment of hypertension, the burden of hypertension remains a major global health care concern. In Japan, estimates show that more than two-thirds of the population have uncontrolled hypertension, regardless of whether they were taking antihypertensive medication. To improve hypertension management, hypertension guidelines have been developed and updated regularly by hypertension societies across various countries and regions. The Japanese Society of Hypertension (JSH) updated the Guidelines for the Management of Hypertension in 2019 (JSH 2019). The JSH 2019 aims to establish a standard management strategy for hypertension and provide evidence to all health care providers. One of its updated main features is its proposal for multidisciplinary team-based care (TBC) involving physicians, pharmacists, nurses, dietitians, and other health care providers. The TBC will help initiate and intensify the management of hypertension, as well as combat clinical inertia, which is expected to contribute to uncontrolled blood pressure and subsequent development of cardiovascular diseases. This is consistent with the recommendations from recent major guidelines on hypertension management. Moreover, to reduce the evidence-practice gap in hypertension management, it is essential to disseminate the essence of the guidelines and provide hypertension education programs for all health care providers and patients. This review summarizes the points of the JSH 2019-based strategy for improving hypertension management and discusses guidelines for its implementation into actual clinical practice.

Community Pharmacy-Based Blood Pressure Screening in Newfoundland and Labrador, Canada for World Hypertension Day 2022: A Cross-Sectional Study

Background

High blood pressure (BP) is a leading cause of cardiovascular and stroke-related events. Office-based BP measurement has declined in recent years due to the COVID-19 pandemic, which may have resulted in higher rates of undetected and uncontrolled hypertension. To gain a better idea of adult BP levels in Newfoundland and Labrador, we engaged community pharmacists in BP screening on World Hypertension Day.

Methods

Data collection and BP screening occurred on May 17, 2022. Pharmacists and pharmacy students collected 3 seated BP readings from participants, using an automated device. The average of readings 2 and 3 was used to estimate BP, with elevated BP defined as ≥ 140/90 mm Hg, or ≥ 130/80 mm Hg for individuals with diabetes. Data on participant demographics, access to primary care, medical history, and antihypertensive use were also collected. Data analysis included descriptive statistics and logistic regression techniques.

Results

A total of 460 participants were included in the analysis. The mean age was 56.3 years (standard deviation: 16.95); 63.3% (n = 291) were female; and 43.7% (n = 201) reported having hypertension. Elevated BP was identified in 27% (n = 123). Of those with elevated BP, 41.5% (n = 51) had no history of diagnosed hypertension. Age, sex, and diabetes were statistically significant predictors of elevated BP in the multivariable model.

Conclusions

A large proportion of participants in our study had elevated BP. Targeted measures are needed to improve the detection, treatment, and control of high BP in Newfoundland and Labrador. Community pharmacists can support BP care.

The role of Lesotho community pharmacists in preventing and controlling cardiovascular diseases: The perceived facilitators and barriers

BACKGROUND

Cardiovascular diseases are a leading cause of mortality globally. The impact of cardiovascular diseases can be minimized by addressing modifiable risk factors at primary health care level. Community pharmacists are well-positioned to identify patients at risk of cardiovascular diseases for early detection and initiation of treatment. However, the role of Lesotho community pharmacists in preventing and controlling cardiovascular diseases is not well understood. The purpose of this study was to explore the Lesotho community pharmacists' role in preventing and controlling cardiovascular diseases.

METHODS

The methodological reporting of this study was guided by the consolidated criteria for reporting qualitative studies. A list of registered community pharmacists was obtained from the Ministry of Health. Pharmacists were selected based on their close proximity to the researcher and invited to participate. Semi-structured interviews were conducted until data saturation was reached. The interviews were audio-recorded, transcribed verbatim, and analysed thematically.

RESULTS

Five themes were identified namely: 1) Current roles 2) Future role 3) Facilitators, 4) Barriers, and 5) Community pharmacists' perceptions of their roles. Generally, community pharmacists were involved in medication counselling, health promotion, and referral of patients. Lack of support from government, patients' lack of adherence, poor interprofessional relationship, and lack of clear community pharmacy practice guidelines were identified as barriers. Despite the challenges, community pharmacists are motivated by patients' gratitude for their services.

CONCLUSIONS

Lesotho community pharmacists can potentially improve cardiovascular diseases' health outcomes at primary healthcare level through early detection of CVD risk factors, and health promotion.

Preventing cognitive decline by reducing BP target (PCOT): A randomized, pragmatic, multi-health systems clinical trial

BACKGROUND

Growing evidence suggests that intensive lowering of systolic blood pressure (BP) may prevent mild cognitive impairment (MCI) and dementia. However, current guidelines provide inconsistent recommendations regarding optimal BP targets, citing safety concerns of excessive BP lowering in the diverse population of older adults. We are conducting a pragmatic trial to determine if an implementation strategy to reduce systolic BP to <130 and diastolic BP to <80 mmHg will safely slow cognitive decline in older adults with hypertension when compared to patients receiving usual care.

METHODS

The Preventing Cognitive Decline by Reducing BP Target Trial (PCOT) is an embedded randomized pragmatic clinical trial in 4000 patients from two diverse health-systems who are age ≥ 70 years with BP >130/80 mmHg. Participants are randomized to the intervention arm or usual care using a permuted block randomization within each health system. The intervention is a combination of team-based care with clinical decision support to lower home BP to <130/80 mmHg. The primary outcome is cognitive decline as determined by the change in the modified Telephone Interview for Cognitive Status (TICS-m) scores from baseline. As a secondary outcome, patients who decline ≥3 points on the TICS-m will complete additional cognitive assessments and this information will be reviewed by an expert panel to determine if they meet criteria for MCI or dementia.

CONCLUSION

The PCOT trial will address the effectiveness and safety of hypertension treatment in two large health systems to lower BP targets to reduce risk of cognitive decline in real-world settings.

Demonstrating the Benefits of Antihypertensive Nighttime Dosing and Indapamide Usage in Hypertension Management

Background: Uncontrolled hypertension, specifically nocturnal hypertension, increases the risk for significant clinical outcomes. Evidence on the use of nighttime antihypertensives is scant and conflicting. In addition, hydrochlorothiazide continues to be the primary thiazide used despite being the least potent. Objective: The primary purpose of this study was to evaluate instituting nighttime dosing to control hypertension and compare the short-term effectiveness of blood pressure control with indapamide versus hydrochlorothiazide. Methods: This was a retrospective, observational study. Participant inclusion criteria consisted of patients 18 years of age or older, a current diagnosis of hypertension, and hypertension that required medical therapy. The investigator documented whether a patient was taking at least one antihypertensive at night versus all morning medications, as well as the use of indapamide versus hydrochlorothiazide. The patient's baseline and first follow-up blood pressure readings were documented. The primary outcome was to determine whether including nighttime dosing in antihypertensive regimens is more effective than all morning antihypertensive regimens. The secondary outcome was to determine whether indapamide was more effective than hydrochlorothiazide. Results: A total of 64 patients were included in the study. Twenty-eight patients were taking >1 nighttime antihypertensives versus 32 patients on all morning medications. Patients on at least one nighttime medication demonstrated greater systolic blood pressure reduction. There was no difference in blood pressure reduction between indapamide and hydrochlorothiazide. Conclusion: The study findings support the use of nighttime dosing to improve blood pressure management. The results on the effectiveness of indapamide versus hydrochlorothiazide conflict with previous research.

Remote follow-up by pharmacists for blood pressure control in patients with hypertension: a systematic review and a meta-analysis of randomized controlled trials

Hypertension is a major cause of cardiovascular diseases. Several recent studies reported that pharmacists' remote follow-up reduced hypertension patients' blood pressure (BP). This meta-analysis aims to verify whether remote follow-up by pharmacists improves BP levels and reveal the factors that make the intervention effective. The search, conducted using PubMed/Medline, Embase, and Cochrane Library from June to July 2023, targeted articles published between October 1982 and June 2023, using terms including "pharmacist", "hypertension", and "randomized controlled trial (RCT)". The inclusion criteria were: (a) RCTs involving hypertension patients with or without comorbidities, (b) pharmacists using remote communication tools to conduct follow-up encounter during the intervention period, (c) reporting systolic blood pressure (SBP) at baseline and during intervention. SBP was the primary outcome for the meta-analysis. Thirteen studies (3969 participants) were included in this meta-analysis. The mean difference of SBP between intervention group and control group was - 7.35 mmHg (P < 0.0001). Subgroup analyses showed the greater reduction of SBP in the "regularly scheduled follow-up cohort" (- 8.89 mmHg) compared with the "as needed follow-up cohort" (- 3.23 mmHg, P < 0.0001). The results revealed that remote follow-up by pharmacists reduced SBP levels in hypertension patients and scheduled remote follow-up may contribute to the effectiveness.

Using design thinking to strengthen the community pharmacist's role in epilepsy care

OBJECTIVE

To use design thinking to develop a community pharmacist-led intervention for people living with epilepsy (PWE) with desirable, feasible, and viable features.

METHODS

This study used design thinking. Three patient personas were created based on previous research: a newly diagnosed PWE, a well-controlled PWE, and a complex PWE with uncontrolled seizures. An intervention prototype was developed for each of the three personas. Structured interviews were conducted with pharmacists, pharmacy students, patients with diagnosed epilepsy, and caregivers to elicit feedback on which features of each intervention prototype were desirable, feasible, and viable. Interviews were analyzed using rapid content analysis. A multidisciplinary advisory group and the research team prioritized features of the prototypes to include in the final intervention.

RESULTS

The following four features were identified as desirable, feasible, and viable for a pharmacist-led intervention for PWE: (1) pharmacist-patient consultations, (2) care plan development, (3) regular check-ins, and (4) care coordination with other health care providers.

SIGNIFICANCE

This study identified evidence-based features for a community pharmacist intervention to support epilepsy care using design thinking. A pilot study to evaluate this intervention on the quality of life (QoL), health outcomes and satisfaction of PWE can inform the implementation and feasibility of such patient services.

Protocol of a patient randomized clinical trial to improve medication adherence in primary care

BACKGROUND

Enhanced awareness of poor medication adherence could improve patient care. This article describes the original and adapted protocols of a randomized trial to improve medication adherence for cardiometabolic conditions.

METHODS

The original protocol entailed a cluster randomized trial of 28 primary care clinics allocated to either (i) medication adherence enhanced chronic disease care clinical decision support (eCDC-CDS) integrated within the electronic health record (EHR) or (ii) usual care (non-enhanced CDC-CDS). Enhancements comprised (a) electronic interfaces printed for patients and clinicians at primary care encounters that encouraged discussion about specific medication adherence issues that were identified, and (b) pharmacist phone outreach. Study subjects were individuals who at an index visit were aged 18-74 years and not at evidence-based care goals for hypertension (HTN), diabetes mellitus (DM), or lipid management, along with low medication adherence (proportion of days covered [PDC] <80%) for a corresponding medication. The primary study outcomes were improved medication adherence and clinical outcomes (BP and A1C) at 12 months. Protocol adaptation became imperative in response to major implementation challenges: (a) the availability of EHR system-wide PDC calculations that superseded our ability to limit PDC adherence information solely to intervention clinics; (b) the unforeseen closure of pharmacies committed to conducting the pharmacist outreach; and (c) disruptions and clinic closures due to the Covid-19 pandemic.

CONCLUSION

This manuscript details the protocol of a study to assess whether enhanced awareness of medication adherence issues in primary care settings could improve patient outcomes. The need for protocol adaptation arose in response to multiple implementation challenges.

Exploring educational inequalities in hypertension control, salt knowledge and awareness, and patient advice: insights from the WHO STEPS surveys of adults from nine Eastern European and Central Asian countries

OBJECTIVE

To inform strategies aimed at improving blood pressure (BP) control and reducing salt intake, we assessed educational inequalities in high blood pressure (HBP) awareness, treatment and control; physician's advice on salt reduction; and salt knowledge, perceptions and consumption behaviours in Eastern Europe and Central Asia.

DESIGN

Data were collected in cross-sectional, population-based nationally representative surveys, using a multi-stage clustered sampling design. Five HBP awareness, treatment and control categories were created from measured BP and hypertension medication use. Education and other variables were self-reported. Weighted multinomial mixed-effects regression models, adjusted for confounders, were used to assess differences across education categories.

SETTINGS

Nine Eastern European and Central Asian countries (Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, Republic of Moldova, Tajikistan, Turkey and Uzbekistan).

PARTICIPANTS

Nationally representative samples of 30 455 adults aged 25-65 years.

RESULTS

HBP awareness, treatment and control varied substantially by education. The coverage of physician's advice on salt was less frequent among participants with lower education, and those with untreated HBP or unaware of their HBP. The education gradient was evident in salt knowledge and perceptions of salt intake but not in salt consumption behaviours. Improved salt knowledge and perceptions were more prevalent among participants who received physician's advice on salt reduction.

CONCLUSIONS

There is a strong education gradient in HBP awareness, treatment and control as well as salt knowledge and perceived intake. Enhancements in public and patient knowledge and awareness of HBP and its risk factors targeting socio-economically disadvantaged groups are urgently needed to alleviate the growing HBP burden in low- and middle-income countries.

Achievement rate of target blood pressure in patients with hypertension treated by hypertension specialists and non-specialists in a real-world setting

Hypertension remains a major global healthcare issue. Considering that most Japanese patients with hypertension are managed by general practitioners, hypertension specialists should be involved in actual clinical practice. We investigated the blood pressure (BP), guidelines recommended for achievement rate of the target BP, and clinical variables of patients with hypertension treated by hypertension specialists and those treated by non-specialists in a real-world setting. Factors associated with the target BP achievement in this population were also investigated. Outpatients with hypertension from 12 medical facilities in Okinawa Prefecture were enrolled (n = 1469 [specialist group, 794; non-specialist group, 675]; mean age, 64.2 years; females, 45.8%). For all patients, BP and rate of the target BP achievement were 129.0 ± 15.5/74.6 ± 10.6 mmHg, and 51.8%, respectively. BP and the rate of target of BP achievement were 128.0 ± 15.1/73.4 ± 10.4 mmHg and 56.7% in the specialist group, and they were 130.1 ± 15.9/76.0 ± 10.8 mmHg and 46.1% in the non-specialist group. The urinary salt excretion and obesity rates were comparable between the specialist and non-specialist groups. Multivariable logistic analyses indicated that hypertension specialists and good medication adherence were positive factors, whereas obesity, chronic kidney disease, diabetes mellitus, and urinary salt excretion were inverse factors associated with target BP achievement in this population. Initiatives for salt reduction, medication adherence, and proper obesity management are crucial to improving BP management in patients with hypertension. Hypertension specialists are expected to play an essential role in them. For all patients, the target blood pressure (BP) achievement rate were 51.8%. Hypertension specialists and good medication adherence were positive factors in achieving target BP; conversely, obesity, diabetes mellitus, chronic kidney disease, and high urinary salt excretion were inverse factors in achieving target BP among patients with hypertension.

Cost-Effectiveness of Pharmacist Prescribing for Managing Hypertension in the United States

Importance

Pharmacist-led interventions can significantly improve blood pressure (BP) control. The long-term cost-effectiveness of pharmacist-prescribing interventions implemented on a large scale in the US remains unclear.

Objective

To estimate the cost-effectiveness of implementing a pharmacist-prescribing intervention to improve BP control in the US.

Design, Setting, and Participants

This economic evaluation included a 5-state Markov model based on the pharmacist-prescribing intervention used in The Alberta Clinical Trial in Optimizing Hypertension (or RxACTION) (2009 to 2013). In the trial, control group patients received an active intervention, including a BP wallet card, education, and usual care. Data were analyzed from January to June 2023.

Main Outcomes and Measures

Cardiovascular (CV) events, end-stage kidney disease events, life years, quality-adjusted life years (QALYs), lifetime costs, and lifetime incremental cost-effectiveness ratio (ICER). CV risk was calculated using Framingham risk equations. Costs were based on the reimbursement rate for level 1 encounters, medication costs from published literature, and event costs from national surveys and pricing data sets. Quality of life was determined using a published catalog of EQ-5D utility values. One-way sensitivity analyses were used to assess alternative reimbursement values, a reduced time horizon of 5 years, alternative assumptions for BP reduction, and the assumption of no benefit to the intervention after 10 years. The model was expanded to the US population to estimate population-level cost and health impacts.

Results

Assumed demographics were mean (SD) age, 64 (12.5) years, 121 (49%) male, and a mean (SD) baseline BP of 150/84 (13.9/11.5) mm Hg. Over a 30-year time horizon, the pharmacist-prescribing intervention yielded 2100 fewer cases of CV disease and 8 fewer cases of kidney disease per 10 000 patients. The intervention was also associated with 0.34 (2.5th-97.5th percentiles, 0.23-0.45) additional life years and 0.62 (2.5th-97.5th percentiles, 0.53-0.73) additional QALYs. The cost savings were $10 162 (2.5th-97.5th percentiles, $6636-$13 581) per person due to fewer CV events with the pharmacist-prescribing intervention, even after the cost of the visits and medication adjustments. The intervention continued to produce benefits in more conservative analyses despite increased costs as the ICER ranged from $2093 to $24 076. At the population level, a 50% intervention uptake was associated with a $1.137 trillion in cost savings and would save an estimated 30.2 million life years over 30 years.

Conclusion and Relevance

These findings suggest that a pharmacist-prescribing intervention to improve BP control may provide high economic value. The necessary tools and resources are readily available to implement pharmacist-prescribing interventions across the US; however, reimbursement limitations remain a barrier.

Effect of Pharmaceutical Intervention in Pharmacologically Treated Hypertensive Patients-A Cluster-Randomized Clinical Trial: AFPRES-CLM Study

BACKGROUND

Evaluate the effect of a community pharmaceutical intervention on the control of blood pressure in hypertensive patients treated pharmacologically.

METHODS

A cluster-randomized clinical trial of 6 months was carried out. It was conducted in the Autonomous Community of Castilla-La Mancha (Spain). Sixty-three community pharmacies and 347 patients completed the study. Intervention patients received the community pharmaceutical intervention based on a protocol that addresses the individual needs of each patient related to the control of their blood pressure, which included Health Education, Pharmacotherapy Follow-up and 24 h Ambulatory Blood Pressure Measurement. Control patients received usual care in the community pharmacy.

RESULTS

The pharmaceutical intervention resulted in better control of blood pressure (85.8% vs. 66.3% p < 0.001), lower use of emergencies (p = 0.002) and improvement trends in the physical components of quality of life, measured by SF-36 questionnaire, after 6 months of pharmaceutical intervention. No significant changes were observed for any of these variables in the control group. There were also detected 354 negative medication-related outcomes that were satisfactorily resolved in a 74.9% of the cases and 330 healthcare education interventions and 29 Ambulatory Blood Pressure Monitorings were performed in order to increase adherence to pharmacological treatment and minimize Negative Outcomes associated with Medication and prevent medication-related problems.

CONCLUSIONS

Community pharmaceutical intervention can increase hypertensive patients with controlled blood pressure, after 6 months, compared with usual care.

Impact of Ambulatory Care Pharmacist-Led Management on Hemoglobin A1c Values among Patients with Uncontrolled Diabetes in a Primary Care Clinic vs Usual Care over Two Years

Background: Literature has shown the positive impact of ambulatory care pharmacists on diabetes management, yet additional research on clinical outcomes compared to traditional care models is warranted. Objective: The objective of this study is to evaluate the impact of an ambulatory care pharmacist on glycemic control over two years compared to patients who received usual care. Methods: This retrospective cohort study matched patients with a baseline hemoglobin A1c (HgbA1c) ≥8% managed by the ambulatory care pharmacist to patients who received usual care. The primary outcome was the mean change in HgbA1c over two years. The secondary outcomes were to evaluate the difference in (1) the proportion of patients achieving HgbA1c <8%, (2) the proportion of patients achieving blood pressure <130/80 mmHg, (3) mean LDL, (4) the proportion of patients prescribed SGLT2 inhibitors, GLP-1RA, and sulfonylureas, and (5) severe hypoglycemia after two years. Results: Data for 180 patients was analyzed over two years. The mean HgbA1c was 10% at baseline vs 8.2% after two years (adjusted mean change -1.92) among pharmacist-managed patients, compared to 9.9% vs 9% respectively for usual care patients (adjusted mean change -0.98) (p=0.004). Among pharmacist-managed patients, 53.5% achieved HgbA1c <8% compared with 34.2% of usual care patients (p=0.014). There were no statistically significant differences in proportion of patients at goal blood pressure, mean LDL, or hypoglycemia between the two groups. After two years, 18.3% of pharmacist-managed and 5.8% of usual care patients were on an SGLT2 inhibitor (p=0.008), and 46.7% of pharmacist-managed and 9.2% of usual care patients were on a GLP-1RA (p<0.001). No difference was found in sulfonylurea utilization. Conclusion: Patients with HgbA1c >8% managed by an ambulatory care pharmacist had twice the HgbA1c reduction and significantly more utilization of GLP-1RA and SGLT2 inhibitors as compared to controls provided usual care.

Analysis of factors affecting pharmacists' ability to identify and solve problems

BACKGROUND

Among Japanese pharmacists, there is a gap in their commitment to self-improvement and a possible gap in their ability to identify and solve problems. However, the factors causing this situation have not yet been clarified. This study was conducted to identify factors that influence the abilities of Japanese pharmacists to identify and solve problems, which are skills considered essential for this profession. A prior history of presenting at academic conferences was set as a surrogate outcome to clarify whether having this experience affects the factors.

METHODS

A nationwide internet-based survey was conducted among 300 participating hospitals and 300 community pharmacists. The survey was discontinued when the sample size of each group reached 300. The respondents were categorized into two groups on the basis of their experience of presenting at academic conferences in the survey item "status of self-improvement after employment." Their association with other survey items was determined using univariate and multivariate logistic regression analyses.

RESULTS

The multivariate analysis revealed that 152 (50.7%) hospital pharmacists and 41 (13.7%) community pharmacists had presented at academic conferences. Among the hospital pharmacists, the experience of presenting at academic conferences was significantly associated with the "age 30 s (*references 20 s)," "presence of pharmacists to consult," "experience supervising interns," and "number of types of self-improvement" factors. For the community pharmacists, prior conference presentation experience was significantly associated with "age over 70 s," "highest educational background (doctoral or master's degree)," and "number of types of self-improvement."

CONCLUSION

This pioneering study suggests that having prior experience of presenting at academic conferences as a surrogate outcome of pharmacists' problem-finding and problem-solving skills may be related to the support provided by human environmental factors at the facility, the status of self-improvement, and the highest educational background.

Assessment of knowledge, attitude, and practice of primary healthcare physicians in Qatar towards hypertension management: An online cross-sectional study

Primary health care is integral to diagnosing and managing hypertension. This study aimed to assess the knowledge, attitude, practice, priority, and confidence of primary care physicians in Qatar toward hypertension diagnosis and management, and to measure the determinants of good knowledge, desirable attitudes, and desirable practices. We conducted a cross-sectional web-based survey using a modified version of the World Hypertension League Questionnaire during the period from August 30th to October 23rd, 2020. All primary care physicians working in any of Qatar's 27 publicly run primary healthcare centers were invited to participate in the survey. Out of the 450 primary care physicians working at that time, 197 completed the study questionnaire with a response rate of 43.8%. Most respondents stated that they followed local or international treatment guidelines for hypertension management (96.4%). Primary care physicians were highly confident and prioritized hypertension management. The overall desirable practice score was 73.8%, with the highest score (95.4%) for assessing adherence to antihypertensive medications, whereas the lowest desirable practice score was 33.5% for counseling on home blood pressure monitoring. Fifty-one-point eight percentage and 62.4% correctly identified 140 mm Hg and 90 mm Hg as the systolic and diastolic blood pressure threshold for diagnosing hypertension in most patients. The lowest knowledge scores were for hypertension epidemiology in Qatar and recommended dietary modification for hypertensive patients. Respondents had positive attitudes toward task sharing with nonphysician healthcare workers for most items (58.9%-78.2%), except for drug prescriptions (30.5%). Primary care physicians in Qatar had positive attitudes, with high overall confidence and conviction (priority) scores toward hypertension. However, their knowledge scores and certain practices were suboptimal. Healthcare policymakers in Qatar should raise primary care physicians awareness of the current burden of untreated hypertension in the country by organizing targeted educational programs and emphasizing the importance of following national clinical practice guidelines in the diagnosis and management of hypertension.

A systematic review of the role of community pharmacists in the prevention and control of cardiovascular diseases: the perceptions of patients

BACKGROUND

Cardiovascular diseases are a leading cause of mortality globally. The modifiable risk factors can be measured and identified early at primary healthcare facilities. Community pharmacists present an opportunity for improved management of cardiovascular diseases and health outcomes. The systematic review aims to identify the roles of community pharmacists in preventing and controlling cardiovascular diseases and patients' perceptions towards such functions.

METHODS

A systematic review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The team searched MEDLINE, CINAHL via EBSCOhost, and Web of Science from January 2001 to December 2021 with a focus on studies reporting the role of community pharmacists in preventing and controlling cardiovascular diseases, and patients' perceptions of such roles. Search terms included were ''interventions,'' ''community pharmacists,'' ''patients,'' ''cardiovascular diseases,'' ''risk factors,'' and "perceptions". The quality of studies was appraised using the Joanne Briggs Institute checklist.

RESULTS

A total of 45 studies met the inclusion criteria: 35 (78%) and 10 (22%) reported community pharmacists' preventive and control roles, respectively. Generally, drug therapy monitoring, medicine and lifestyle counselling, and health education were most common roles, with pharmacist-initiated prescribing and social support least common. A total of 11 (24%) studies reported patients' perceptions of community pharmacists' contribution in preventing (73%, n = 8) and controlling (27%, n = 3) cardiovascular diseases. Patients were satisfied with community pharmacists' services in 10 of 11 studies.

CONCLUSIONS

The findings highlight community pharmacists' capability of providing primary healthcare services in preventing and controlling cardiovascular diseases and provide evidence for their inclusion in primary healthcare frameworks. Future research should assess the effectiveness of these roles and provide a comprehensive evaluation of clinical, humanistic, and economic outcomes.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework (OSF) registration https://doi.org/10.17605/OSF.IO/WGFXT .

Comparative outcomes associated with rivaroxaban versus warfarin use in elderly patients with atrial fibrillation or acute venous thromboembolism managed in the United States: a systematic review of observational studies

BACKGROUND

Advancing age is a risk factor for developing non-valvular atrial fibrillation (NVAF) or acute venous thromboembolism (VTE). We assessed the comparative effectiveness, safety, costs, and healthcare utilization associated with rivaroxaban versus warfarin in patients of advanced age managed in the United States (US).

METHODS

We conducted a systematic review of Medline and Embase through April 2023 to identify real-world evidence (RWE) studies of older adults (at least 65+ years of age) with either NVAF or VTE who received either rivaroxaban or warfarin in the US and reported an outcome of stroke or systemic embolism (SSE), ischemic stroke (IS), recurrent VTE, major bleeding, intracranial hemorrhage, costs, or healthcare resource utilization. We classified each outcome of interest per study as "positive" (lower risk), "negative" (higher risk), or "neutral" based upon the summary effect size of rivaroxaban versus warfarin.

RESULTS

Twenty-nine RWE studies met inclusion criteria, mostly (83%) in NVAF populations. For SSE with rivaroxaban versus warfarin, 68.8% of studies showed positive effects and 31.2% showed neutral outcome. For major bleeding, 57.7% showed neutral effects, 38.5% showed negative effects, and 3.8% of studies showed positive effects with rivaroxaban versus warfarin. Of the two studies reporting cost data, both were positive, showing lower costs for SSE for rivaroxaban versus warfarin and neutral cost for major bleeding costs.

CONCLUSIONS

This systematic review supports findings from subgroup analyses of randomized controlled trials that, compared with warfarin, rivaroxaban is associated with generally neutral or positive effects on thrombosis and a mixed picture on bleeding outcomes in older adults with either NVAF or VTE treated in the United States.

Rural-urban trends in health care utilization, treatment, and mortality among US veterans with congestive heart failure: A retrospective cohort study

PURPOSE

To compare longitudinal rates of health care utilization, evidence-based treatment, and mortality between rural and urban-dwelling patients with congestive heart failure (CHF).

METHODS

We used electronic medical record data from the Veterans Health Administration (VHA) to identify adult patients with CHF from 2012 through 2017. We stratified our cohort using left ventricular ejection fraction percentage at diagnosis (<40% = reduced ejection fraction [HFrEF]; 40%-50% = midrange ejection fraction [HFmrEF]; >50% = preserved ejection fraction [HFpEF]). Within each ejection fraction cohort, we stratified patients into rural or urban groups. We used Poisson regression to estimate annual rates of health care utilization and CHF treatment. We used Fine and Gray regression to estimate annual hazards of CHF and non-CHF mortality.

FINDINGS

One-third of patients with HFrEF (N = 37,928/109,110), HFmrEF (N = 24,447/68,398), and HFpEF (N = 39,298/109,283) resided in a rural area. Rural compared to urban patients used VHA facilities at similar or lower annual rates for outpatient specialty care across all ejection fraction cohorts. Rural patients used VHA facilities at similar or higher rates for primary care and telemedicine-delivered specialty care. They also had lower and declining rates of VHA inpatient and urgent care use over time. There were no meaningful rural-urban differences in treatment receipt among patients with HFrEF. On multivariable analysis, the rate of CHF and non-CHF mortality was similar between rural and urban patients in each ejection fraction cohort.

CONCLUSIONS

Our findings suggest the VHA may have mitigated access and health outcome disparities typically observed for rural patients with CHF.

Recommendations for wider adoption of clinical pharmacy in Central and Eastern Europe in order to optimise pharmacotherapy and improve patient outcomes

Clinical pharmacy as an area of practice, education and research started developing around the 1960s when pharmacists across the globe gradually identified the need to focus more on ensuring the appropriate use of medicines to improve patient outcomes rather than being engaged in manufacturing and supply. Since that time numerous studies have shown the positive impact of clinical pharmacy services (CPS). The need for wider adoption of CPS worldwide becomes urgent, as the global population ages, and the prevalence of polypharmacy as well as shortage of healthcare professionals is rising. At the same time, there is great pressure to provide both high-quality and cost-effective health services. All these challenges urgently require the adoption of a new paradigm of healthcare system architecture. One of the most appropriate answers to these challenges is to increase the utilization of the potential of highly educated and skilled professionals widely available in these countries, i.e., pharmacists, who are well positioned to prevent and manage drug-related problems together with ensuring safe and effective use of medications with further care relating to medication adherence. Unfortunately, CPS are still underdeveloped and underutilized in some parts of Europe, namely, in most of the Central and Eastern European (CEE) countries. This paper reviews current situation of CPS development in CEE countries and the prospects for the future of CPS in that region.

Real-World Effectiveness in Hypertension and Hyperlipidemia Collaborative Management between Pharmacies and Primary Care in Portugal: A Multicenter Pragmatic Controlled Trial (USFarmácia®)

There is evidence of the efficacy of collaborative health interventions with pharmacies and primary care providers but little of its real-world effectiveness. We aimed to assess the effectiveness and discuss the design and challenges of hypertension and hyperlipidemia management between pharmacies and primary care providers using real-world data exchange between providers and experimental bundled payment. This was a pragmatic, quasi-experimental controlled trial. We collected patient-level data from primary care prescription claims and Electronic Medical Record databases, a pharmacy claims database, and patient telephone surveys at several time points. The primary outcomes were changes in blood pressure and total cholesterol. We used matched controls with difference-in-differences estimators in a Generalized Linear Model (GLM) and controlled interrupted time series (CITS). We collected additional data for economic and qualitative studies. A total of 6 Primary Care Units, 20 pharmacies, and 203 patients entered the study. We were not able to observe significant differences in the effect of intervention vs. control. We experienced challenges that required creative strategies. This real-world trial was not able to show effectiveness, likely due to limitations in the primary care technology which affected the sample size. It offers, however, valuable lessons on methods, strategies, and data sources, paving the way for more real-world effectiveness trials to advance value-based healthcare.

Landscape of team-based care to manage hypertension: results from two surveys in low/middle-income countries

OBJECTIVES

Team-based care is essential for improving hypertension outcomes in low-resource settings. We assessed perceptions of country representatives and healthcare workers (HCWs) on team-based hypertension care in low/middle-income countries.

DESIGN

Two cross-sectional surveys.

SETTING

The first survey (Country Profile Survey) was conducted in 17 countries and eight in-country regions: Algeria, Bangladesh, Burundi, Chile, China (Beijing, Henan, Shandong), Cuba, Ethiopia, India (Kerala, Madhya Pradesh, Maharashtra, Punjab, Telangana), Nepal, Nigeria, Philippines, Saint Lucia, Sri Lanka, Thailand, Turkey, Uganda and Vietnam. The second survey (HCW Survey) was conducted in four countries: Bangladesh, China, Ethiopia and Nigeria.

PARTICIPANTS

Using convenience sampling, participants for the Country Profile Survey were representatives from 17 countries and eight in-country regions, and the HCW Survey was administered to HCWs in Bangladesh, China, Ethiopia and Nigeria.

OUTCOME MEASURES

Country-level use of team-based hypertension care framework, comprising administrative, basic and advanced clinical tasks. Current practices of different HCW cadres, perspectives on team-based management of hypertension, barriers and facilitators.

RESULTS

In the Country Profile Survey, all (23/23, 100%) countries/regions surveyed integrated team-based care for basic clinical hypertension management tasks, less for advanced tasks (7/23, 30%). In the HCW Survey, 854 HCWs participated, 47% of whom worked in rural settings. Most HCWs in the sample acknowledged the value of team-based hypertension care. Although there were slight variations by country in the study sample, overall, barriers to team-based hypertension care were identified as inadequate training (83%); regulatory issues (76%); resistance by patients (56%), physicians (42%) and nurses (40%). Facilitators identified were use of treatment algorithms (94%), telehealth/m-health technology (92%) and adequate compensation for HCWs (80%).

CONCLUSIONS

Our findings revealed key lessons for health systems and governments regarding team-based care implementation. Specifically, policies to facilitate additional training, optimise HCWs' roles within care teams, use of hypertension treatment protocols and telehealth/m-health technology will be essential to promote team-based care.

Effect of Medication Therapy Management by Pharmaceutical Care on Blood Pressure and Cardiovascular Risk in Hypertension: A Systematic Review, Meta-Analysis, and Meta-Regression

Medication therapy management by pharmaceutical care (MTM-PC) has been shown to improve the effectiveness of antihypertensive treatments. The aim was to answer the question: what are the MTM-PC models and their impact on hypertensive patients' outcomes? This is a systematic review with meta-analysis. The search strategies were run on 27 September 2022 in the following databases: PubMed, EMBASE, Scopus, LILACs, Central Cochrane Library, Web of Science; and International Pharmaceutical Abstracts. The quality and bias risk was assessed by the Downs and Black instrument. Forty-one studies met the eligibility criteria and were included, Kappa = 0.86; 95% CI, 0.66-1.0; (p < 0.001). Twenty-seven studies (65.9%) had MTM-PC models outlined by the clinical team, showing as characteristics the mean of 10.0 ± 10.7 months of follow-up of hypertensive patients, with 7.7 ± 4.9 consultations. Instruments to assess the quality of life measured the enhancement by 13.4 ± 10.7% (p = 0.047). The findings of the meta-analysis show a mean reduction of -7.71 (95% CI, -10.93 to -4.48) and -3.66 (95% CI, -5.51 to -1.80), (p < 0.001) in mmHg systolic and diastolic pressures, respectively. Cardiovascular relative risk (RR) over ten years was 0.561 (95% CI, 0.422 to 0.742) and RR = 0.570 (95% CI, 0.431 to 0.750), considering homogeneous studies, I² = 0%. This study shows the prevalence of MTM-PC models outlined by the clinical team, in which there are differences according to the models in reducing blood pressure and cardiovascular risk over ten years with the improvement in quality of life.

Physician-Pharmacist Collaborative Drug Therapy Management in Pediatric Hypertension

OBJECTIVE

Pediatric hypertension affects 2% to 5% of children and adolescents in the United States and is frequently undertreated. The increasing prevalence of pediatric hypertension and worsening physician shortage create difficulties in closing this treatment gap. Physician-pharmacist collaborations have been shown to improve patient outcomes in adult patients. Our aim was to demonstrate a similar benefit for pediatric hypertension.

METHODS

Pediatric patients whose hypertension was managed at a single pediatric cardiology clinic from January 2020 to December 2021 were enrolled in collaborative drug therapy management (CDTM). Patients whose hypertension was managed in the same clinic from January 2018 to December 2019 were used as a comparison group. The primary outcomes were achievement of at-goal blood pressure at 3, 6, and 12 months and time to control of hypertension. Secondary outcomes were appointment adherence and serious adverse events.

RESULTS

A total of 151 patients were included in the CDTM group, and 115 patients were included in the traditional care group. Of those, 100 CDTM patients and 78 traditional care patients were assessed for the primary outcome. Fifty-four (54%) CDTM patients and 28 (36%) traditional care patients achieved at-goal blood pressure at 12 months (OR, 2.09; 95% CI, 1.14-3.85). Appointment non-adherence was 9.4% for CDTM and 16% for traditional care (OR, 0.54; 95% CI, 0.35-0.82). Adverse events were similar between groups.

CONCLUSIONS

CDTM increased rates of at-goal blood pressure without increased adverse events. Physician-pharmacist collaboration may improve treatment of hypertension in pediatric patients.

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.

Pharmacist interventions to improve blood pressure control in primary care: a cluster randomised trial

BACKGROUND

High blood pressure (BP) is the single largest contributor to mortality world-wide.

AIM

To investigate the effectiveness of a pharmacists-led intervention to improve BP control using automated office blood pressure (AOBP).

METHOD

In this prospective parallel group, unblinded, cluster-randomised trial, 54 pharmacies enrolled pre-treated patients with uncontrolled AOBP above 135/85 mmHg. In the interventional group, pharmacists referred patients to the treating physician for therapy intensification in a structured fashion. In the control group, AOBP was recorded until the end of the trial. The primary endpoint was the proportion of patients achieving BP control at the threshold of 135/85 mmHg after 10 weeks. Key secondary endpoints were systolic AOBP reductions after 10 and 20 weeks.

RESULTS

A total of 497 patients were included between 2017 and 2019. In the interventional and control group, 61.5% and 19.8% of patients underwent a therapy modification within 20 weeks. The primary endpoint was achieved in 38.8% in the interventional group and 31.2% in the control group (mean difference 7.6%, 95% CI -8.1; 23.3, p = 0.336). Mean systolic AOBP reductions were greater in the interventional vs. control group at 10 and 20 weeks (14.3 ± 7.4 vs. 6.9 ± 7.0 mmHg, mean difference 7.3 mmHg, 95% CI 3.2;11.5, p < 0.001, and 15.5 ± 9.0 vs. 9.8 ± 7.5 mmHg, mean difference 5.8 mmHg, 95% CI 0.8;10.7, p = 0.023). Atrial fibrillation was newly detected in 7.8% of patients.

CONCLUSION

Through a pragmatic pharmacist-led disease management program, BP control was improved over time, without significant differences between groups. Greater systolic AOBP reductions were observed in the interventional vs. control group. (Pharmacists Intervention to Improve Hypertension Management in Primary Care:APOTHECARE; ClinicalTrials.gov registration NCT03274531).

High blood pressure screening in pharmacies during May Measurement Month campaigns in Switzerland

PURPOSE

May Measurement Month (MMM) is an international screening campaign for arterial hypertension (HT) organised by the International Society of Hypertension and the World Hypertension League. It aims at raising the awareness of elevated blood pressure (BP) in the population. The goal of this analysis was to assess the results obtained in Swiss pharmacies during a 3-year campaign.

MATERIAL AND METHODS

Swiss data from the MMM17 to MMM19 campaigns were extracted from the global MMM database. The analysis was conducted specifically on measures taken in pharmacies. BP and a questionnaire including demographical and clinical information were recorded for each participant. To assess BP control, ESH 2018 thresholds of <140/90 mmHg and ESH 2021 pharmacy-thresholds of <135/85 mmHg were used.

RESULTS

From an initial sample of 3634 Swiss participants included during this 3-year campaign, 2567 participants (73.2%women and 26.8% men, p<.001) had their BP measured in triplicates in pharmacies. The first BP measurement was associated with 2.0 ± 4.9 mmHg effect on systolic blood pressure (SBP) (p<.001) and 0.7 ± 3.7 mmHg on diastolic blood pressure (DBP) (p<.001) compared to the mean of the second and third measurements. Based on the ESH 2018 and the ESH 2021 pharmacy thresholds, prevalence of HT (mean of second and third measurements) increased from 29.5% to 38.3%, respectively. In treated participants, 58.3% (279) had an average BP < 140/90 mmHg and 40.3% (193) had an average BP < 135/85 mmHg.

CONCLUSIONS

HT screening campaigns in pharmacies recruits mainly women. It helps the detection of untreated hypertensive participants and uncontrolled treated participants. Our data suggest that the average BP should be calculated on the second and third measurements due to a significant first measure effect in pharmacies measurement. SummaryHigh blood pressure (BP) is a major global public health issue as the leading risk factor of global death.World-wide initiatives like May Measurement Month (MMM) aim to screen thousands of people each year to raise awareness of hypertension (HT).Switzerland participated in MMM 2017-2019 and screened more than 2500 participants in pharmacies.When adopting the recent proposed thresholds of HT diagnosis in pharmacies (ESH 2021 > 135/85 mmHg), HT prevalence in Switzerland is high (38.3%) with only 2/3 of treated hypertensive achieving the BP goals.Women are more likely to participate in such campaigns taking place in pharmacies.A first measurement effect (FME) was also present in pharmacies, highlighting that taking three BP measurements in pharmacies and discarding the first should be also considered in the pharmacy setting.Involving a routine pharmacy-based health care of patients would help to identify more hypertensive patients and uncontrolled treated patients, who may not have had access to BP measurement.

Comparing Pharmacist-Led Telehealth Care and Clinic-Based Care for Uncontrolled High Blood Pressure: The Hyperlink 3 Pragmatic Cluster-Randomized Trial

BACKGROUND

A team approach is one of the most effective ways to lower blood pressure (BP) in uncontrolled hypertension, but different models for organizing team-based care have not been compared directly.

METHODS

A pragmatic, cluster-randomized trial compared 2 interventions in adult patients with moderately severe hypertension (BP≥150/95 mm Hg): (1) clinic-based care using best practices and face-to-face visits with physicians and medical assistants; and (2) telehealth care using best practices and adding home BP telemonitoring with home-based care coordinated by a clinical pharmacist or nurse practitioner. The primary outcome was change in systolic BP over 12 months. Secondary outcomes were change in patient-reported outcomes over 6 months.

RESULTS

Participants (N=3071 in 21 primary care clinics) were on average 60 years old, 47% male, and 19% Black. Protocol-specified follow-up within 6 weeks was 32% in clinic-based care and 27% in telehealth care. BP decreased significantly during 12 months of follow-up in both groups, from 157/92 to 139/82 mm Hg in clinic-based care patients (adjusted mean difference -18/-10 mm Hg) and 157/91 to 139/81 mm Hg in telehealth care patients (adjusted mean difference -19/-10 mm Hg), with no significant difference in systolic BP change between groups (-0.8 mm Hg [95% CI, -2.84 to 1.32]). Telehealth care patients were significantly more likely than clinic-based care patients to report frequent home BP measurement, rate their BP care highly, and report that BP care visits were convenient.

CONCLUSIONS

Telehealth care that includes extended team care is an effective and safe alternative to clinic-based care for improving patient-centered care for hypertension.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02996565.

Optimizing Hypertension Control Globally: WHF Roadmap

PURPOSE OF REVIEW

Hypertension represents the most important cardiovascular risk factor, affecting over 4.06 billion adults worldwide. In this review, we will discuss potential barriers and their solutions to improve prevention, detection, and management of hypertension.

RECENT FINDINGS

The prevalence of hypertension has been increasing in low- and middle-income countries, requiring new strategies to improve its recognition and proper management. The World Heart Federation (WHF) developed a roadmap for hypertension, advising health system policies and clinical practices as part of its commitment to improving global cardiovascular health. The World Health Organization (WHO) has published in 2021 practical guidelines for the pharmacological treatment of hypertension in adults. Identifying potential roadblocks and solutions deserves high priority to improve the detection, management, and control of hypertension.

A remote hypertension management program clinical algorithm

INTRODUCTION

Hypertension is the leading risk factor for death, affecting over one billion people worldwide, yet control rates are poor and stagnant. We developed a remote hypertension management program that leverages digitally transmitted home blood pressure (BP) measurements, algorithmic care pathways, and patient-navigator communications to aid patients in achieving guideline-directed BP goals.

METHODS

Patients with uncontrolled hypertension are identified through provider referrals and electronic health record screening aided by population health managers within the Mass General Brigham (MGB) health system. Non-licensed patient navigators supervised by pharmacists, nurse practitioners, and physicians engage and educate patients. Patients receive cellular or Bluetooth-enabled BP devices with which they monitor and transmit scheduled home BP readings. Evidence-based medication changes are made according to a custom hypertension algorithm approved within a collaborative drug therapy management (CDTM) agreement with MGB and implemented by pharmacists. Using patient-specific characteristics, we developed different pathways to optimize medication regimens. The renin-angiotensin-aldosterone system-blocker pathway prescribed ARBs/ACE inhibitors first for patients with diabetes, impaired renal function, and microalbuminuria; the standard pathway started patients on calcium channel blockers. Regimens were escalated frequently, adding thiazide-type diuretics, and including beta blockers and mineralocorticoid receptor antagonists if needed.

DISCUSSION

We have developed an algorithmic approach for the remote management of hypertension with demonstrated success. A focus on algorithmic decision-making streamlines tasks and responsibilities, easing the potential for scalability of this model. As the backbone of our remote management program, this clinical algorithm can improve BP control and innovate the management of hypertension in large populations.

Study of knowledge, attitude and practice regarding patient education in hypertension among community pharmacists in China

Background

In the prevention and treatment of hypertension, patient education is an important measure to improve the awareness rate and control rate of patients. The professional and geographical advantages of community pharmacists enable them to play an important role in the patient education in hypertension. The purpose of this study was to understand the situation of patient education in hypertension conducted in Chinese community pharmacies, and put forward measures according to the problems.

Methods

A multi-stage competitive sampling by convenience was used to select community pharmacists working in community pharmacies in China for the study. Based on KAP theory, the first draft of the questionnaire was designed and the Delphi method was used to improve the questionnaire and a pre-study was conducted to test the reliability of the questionnaire. In January 2020, electronic questionnaires were distributed to 143 community pharmacists in Chinese community pharmacies. SPSS24 software was used for descriptive statistics and subgroup analysis of data.

Results

One hundred and eight valid questionnaires were collected, and the efficiency rate was 75.5%. Most of the respondents were younger than 30 years old (98.1%), and had bachelor’s degree (95.4%). In terms of knowledge, only 15.7% considered themselves "very good" and even 10.2% considered themselves "very bad". Only 35%-55% of respondents answered correctly for patient education content that requires more specialized knowledge, such as treatment and medication. Respondents generally had a positive attitude on the effect of hypertension patient education, but slightly less recognition of their role in patient education. In terms of practice, programs related to patient education have been conducted to different degrees. More than 30% of the community pharmacists interviewed implemented them occasionally or never.

Conclusions

Despite a positive attitude, most of the respondents did not have a high level of knowledge or practice. In China, more research evidence and new guidelines are needed to emphasize the importance and responsibilities of community pharmacists. Continuing education should be certificated at the national level and meet the various needs of community pharmacists. And salary incentives can be tried to motivate them.

Cost-effectiveness and cost-utility of hypertension and hyperlipidemia collaborative management between pharmacies and primary care in portugal alongside a trial compared with usual care (USFarmácia®)

Background: There is little experience in the economic evaluation of pharmacy/primary care collaborative health interventions using interprofessional technology-driven communication under real-world conditions. This study aimed to conduct cost-effectiveness and cost-utility analyses of a collaborative care intervention in hypertension and hyperlipidemia management between pharmacies and primary care versus usual (fragmented) care alongside a trial.

Methods: An economic evaluation was conducted alongside a 6-month pragmatic quasi-experimental controlled trial. Data sources included primary care clinical software; pharmacy dispensing software; patient telephone surveys; and published literature. The target population was adult patients on hypertension and/or lipid-lowering medication. The perspective was societal. We collected patient-level data on resource use to estimate trial costs. Effect outcomes included blood pressure (BP) and quality-adjusted life years (QALYs). Bootstrapping was used to estimate uncertainty around the incremental cost-effectiveness and cost-utility ratios. Cost-effectiveness planes and acceptability curves were estimated.

Results: The intervention was not shown to have reasonable levels of cost-effectiveness or cost-utility when compared to usual care as denoted by the levels of uncertainty expressed in wide confidence intervals. The probability of the intervention being cost-effective is 28% at the threshold of €20,000 per QALY gained and 57% at the threshold of €500 per mmHg systolic BP decrease.

Conclusion: Considering the limitations of the trial which affected effectiveness and economic outcomes, our results are not generalizable for community pharmacy and primary care in Portugal. This research offers, however, valuable lessons on methods and strategies that can be used in future economic evaluations of collaborative public health interventions with the potential for reimbursement.

Clinical trial registration:https://www.isrctn.com/ISRCTN13410498, identifier ISRCTN13410498

Use of clinical pharmacy services by American Indians and Alaska Native adults with cardiovascular disease

Introduction

The Indian Health Service (IHS) and Tribal health programs provide clinical pharmacy services to improve health outcomes among American Indian and Alaska Native (AI/AN) adults with cardiovascular disease (CVD).

Objectives

The study's primary objective was to describe characteristics, including social determinants of health (SDOH), associated with clinical pharmacy utilization by AI/ANs with CVD who accessed IHS/Tribal services. A secondary objective assessed changes in systolic blood pressure (SBP) associated with such utilization.

Methods

Analysis included IHS data for 9844 adults aged 18 and older with CVD who lived in 5 locations. Multivariable logistic regression was used to examine patient characteristics (eg, age, sex, health status, SDOH) associated with clinical pharmacy utilization in fiscal year (FY) 2012. A propensity score model was employed to estimate the association of elevated SBP in FY2013 with FY2012 clinical pharmacy utilization.

Results

Nearly 15% of adults with CVD used clinical pharmacy services. Among adults with CVD, the odds of clinical pharmacy use were higher among adults diagnosed with congestive heart failure (adjusted odds ratio [OR] = 1.22; 95% CI:1.01-1.47), other types of heart disease not including ischemia (OR = 1.40; 95% CI: 1.18-1.65), and vascular disease (OR = 1.23; 95% CI: 1.04-1.46), compared to adults without these conditions. Diabetes (OR = 4.05, 95% CI: 3.29-5.00) and anticoagulation medication use (OR = 20.88, 95% CI: 16.76-20.61) were associated with substantially higher odds of clinical pharmacy utilization. Medicaid coverage (OR = 0.72; 95% CI: 0.56-0.93) and longer travel times to services (OR = 0.87; 95% CI: 0.83-0.92) were each associated with lower odds. FY2012 clinical pharmacy users had lower odds of elevated SBP (OR = 0.71 95% CI: 0.58-0.87) in FY2013 than nonusers.

Conclusion

In addition to health status, SDOH (eg, Medicaid coverage, longer travel times) influenced clinical pharmacy utilization. Understanding characteristics associated with clinical pharmacy utilization may assist IHS/Tribal health programs in efforts to support optimization of these services.

Stakeholders’ Views about the Management of Stable Chronic Conditions in Community Pharmacies

The role of the community pharmacist has evolved to include the provision of more clinical services for patients. Those people who have stable chronic conditions will be managed in community pharmacies. This qualitative study used semi-structured in-depth interviews to understand the potential of providing additional patient-centred care for patients with stable chronic conditions in community pharmacies and identify potential limitations of this approach. Participants were recruited from Welsh Government, Local Health Boards (LHBS), Community Pharmacy Wales (CPW) and the Royal Pharmaceutical Society Wales (RPSW). The interviews were audio-recorded, transcribed verbatim, and analysed thematically. Eight interviews were conducted. The identified themes were as follows: (1) inconsistency and bureaucracy in commissioning pharmacy services; (2) availability of funding and resources; (3) disagreement and uncertainty about the contribution of the community pharmacy sector; (4) continuity of patient medical information and fragmented care; (5) accessibility, capacity and facilities in community pharmacy; (6) pharmacy education and clinical expertise, and (7) patient acceptability. It was clear that the potential benefit of managing stable chronic diseases in community pharmacies was recognised; however, several limitations expressed by stakeholders of pharmacy services need to be considered prior to moving forward.

Impact of Pharmacist-Led Interventions to Improve Clinical Outcomes for Adults With Type 2 Diabetes at Risk of Developing Cardiovascular Disease: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis of randomised controlled trials is to evaluate the impact of pharmacist-led interventions on cardiovascular disease (CVD) risk factors among patients with type 2 diabetes.

METHOD

A literature review was conducted according to PRISMA guidelines using 4 electronic databases: Embase, MEDLINE, CINHAL and the Cochrane Central Register of Controlled Trials. We searched for pharmacist interventions among adults with type 2 diabetes and cardiovascular disease in randomised controlled trials from inception to May 2021 in primary care, diabetes clinics and hospitals. The clinical outcomes measured glycosylated haemoglobin (HbA1c), blood pressure (BP) and lipid profile. The non-clinical outcomes included medication adherence, smoking, health-related quality of life and the cost of the intervention. For the meta-analysis, clinical outcomes were pooled with the random effect model in RevMan 5.3. The Cochrane risk-of-bias tool was used to assess the quality of the included studies.

RESULTS

We retrieved 223 studies,141 of which were included in the review. Ten published articles met the inclusion criteria and were included in the meta-analysis. The pharmacists delivered the interventions alone or collaboratively with other healthcare professionals in hospitals or similar settings. The overall result showed a significant reduction in HbA1c (n = 10; standard deviation in mean value [SDM]: -.53%, 95% CI: -.84, -.23) and systolic BP (n = 10; [SDM]: -.35 mmHg, 95% CI: -.51, -.20) in pharmacist intervention groups. For the non-clinical outcomes, the review revealed variable results from pharmacist intervention compared with those standard care.

CONCLUSION

Pharmacy interventions provide evidence for pharmacists' decisive role in diabetes care management and reducing cardiovascular risk factors among adults with type 2 diabetes.

Pharmacist interventions to improve hypertension management: protocol for a systematic review of randomised controlled trials

INTRODUCTION

Hypertension management remains a major public health challenge in primary care. Innovative interventions to improve blood pressure (BP) control are needed. One approach is through community-based models of care with the involvement of pharmacists and other non-physician healthcare professionals. Our objective is to systematically review the evidence of the impact of pharmacist care alone or in collaboration with other healthcare professionals on BP among hypertensive outpatients compared with usual care. Because these interventions can be complex, with various components, the effect size may differ between the type of interventions. One major focus of our study will be to assess carefully the heterogeneity in the effects of these interventions to identify which ones work best in a given healthcare setting.

METHODS AND ANALYSIS

Systematic searches of the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica (Embase) and Central Register of Controlled Trials (CENTRAL) databases will be conducted. Randomised controlled trials assessing the effect of pharmacist interventions on BP among outpatients will be included. Examples for pharmacist interventions are patient education, feedback to physician and medication management. The outcome will be the change in BP or BP at follow-up or BP control. Results will be synthesised descriptively and, if appropriate, will be pooled across studies to perform meta-analyses. If feasible, we will also perform a network meta-analysis to compare interventions that have not been compared directly head-to-head by using indirect evidence. Heterogeneity in the effect will be evaluated through prespecified subgroup and stratified analyses, accounting notably for the type and intensity of interventions, patients' characteristics and healthcare setting.

ETHICS AND DISSEMINATION

Ethical approval is not required as the results will be drawn from currently available published literature. Outcomes of the review will be shared through peer-reviewed journal and used for implementation policy.

PROSPERO REGISTRATION NUMBER

CRD42021279751.

Clinical and humanistic impact of pharmacotherapeutic follow-up in patients with type 1 diabetes mellitus treated judicially

BACKGROUND

There is a lack of studies that assess the effectiveness of pharmacotherapeutic follow-up in the context of the judicialization of insulin analogues.

AIMS

To evaluate the clinical and humanistic impact of pharmacotherapeutic follow-up in patients with type 1 diabetes mellitus who receive insulin analogues by judicial decision in a Brazilian municipality.

METHODS

A quasi-experimental study of the before-and-after type was carried out through pharmacotherapeutic follow-up. Patients who accepted to participate in the study underwent laboratory tests of glycemic and lipid profile before and after the intervention, and underwent five pharmaceutical consultations. In addition, quality of life and health, knowledge, and skills related to insulin application techniques were analyzed.

RESULTS

28 patients participated in all stages. Of these, most were female (53.6%), with a mean age of 32.8 ± 11.6 years. After the intervention, there was a reduction in blood glucose levels, blood pressure, and increased body mass index. In addition, there was greater knowledge and skills regarding insulin application techniques, improved quality of life, health, greater number of medications used, reduction of pharmacotherapeutic problems, and improvement in eating habits.

CONCLUSION

The pharmacotherapeutic follow-up promoted clinical and humanistic benefits, with improvement in quality of life and health.

Community-Based Rehabilitation Promotes the Functional Recovery of Patients After Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH), a severe disorder with the high death rate, high recurrence rate and high disability rate, affected the quality of human life. Community-based rehabilitation (CBR) helps disabled people at both community and family levels. However, the effect of CBR on the recovery of people after ICH remains unclear.

METHODS

Patients were treated with the CBR training program, subsequently, medication compliance test, clinical neural impairment measurements, functional comprehensive assessments, improved Barthel index score, and life qualities assessments were to performed at 3-month or 6-month intervention of CBR to evaluate the influence of CBR on the medication compliance, physical function and life quality of patients after ICH.

RESULTS

After the treatment of CBR, we observed that, the rate of medication compliance, motor function, functional comprehensive rating scale score, modified Barthel index score, and generic quality of life inventory-74 in the CBR-treated group were significantly higher than that in the control group; the neural impairment measure score in the CBR-treated group was significantly decreased in comparison to the control group.

CONCLUSION

CBR increased the medication compliance, promoted the recovery of the neurological function and improved the life qualities of ICH patients.

Quality of systematic reviews supporting the 2017 ACC/AHA and 2018 ESC/ESH guidelines for the management of hypertension

OBJECTIVE

To assess the methodological and reporting quality of systematic reviews (SRs) that informed recommendations in the recent American and European hypertension guidelines.

DESIGN AND SETTINGS

Meta-epidemiological study. We identified SRs that were cited for class I recommendations based on Level of Evidence-A in the 2017 American College of Cardiology/American Heart Association (ACC/AHA) and the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) hypertension guidelines.

MAIN OUTCOME MEASURES

Methodological and reporting quality of the SRs was assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) checklist and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, respectively.

RESULTS

A total of 40 SRs was included in the analysis (28 from 2017 ACC/AHA; 22 from 2018 ESC/ESH and 10 were included in both). Based on the AMSTAR-2 assessment, only 7.5% SRs were found to be of high methodological quality, 47.5% were of moderate, each 22.5% were of low and critically low quality. Based on the PRISMA checklist assessment, a mean of 24 items (SD (2.76) were reported appropriately, and only five SRs reported all 27 items appropriately.

CONCLUSION

Methodological and reporting quality of SRs were found to vary considerably. Lack of information on the funding source of included studies, use of a protocol, integration of risk of bias assessments while interpreting findings and reporting of excluded studies were major methodological deficiencies.

[Implementing Clinical Evidences into Community Pharmacies: Results of the COMPASS and COMPASS-BP Studies]

Evidence-based medicine (EBM) has led to the development of evidence-based guidelines. The quality of guidelines has been improved by measuring their quality with The Appraisal of Guidelines for Research and Evaluation II (AGREE II) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE). However, evidenced by guidelines not implemented in clinical practice or society, the evidence-practice gap has become apparent. The dissemination and implementation research, which studies methods to solve this problem, has attracted the attention of both clinicians and clinical researchers in recent years. In hypertension and diabetes, it is possible to prevent complications by maintaining good blood pressure and blood glucose levels. However, it is difficult for patients to maintain good laboratory values over the long term, and there has been no solution to this problem. Recently, it has been reported that pharmacists in the U.S. and Canada can improve patient outcomes over the long term by using pharmacies to treat these diseases. This review describes the results of the COMPASS study (diabetes) and the COMPASS-BP study (hypertension), which are the first cluster randomized controlled trials conducted in pharmacies in Japan. In addition, it discusses the possibility of implementation in pharmacies in Japan.

Effects of Pharmacist Interventions on Cardiovascular Risk Factors and Outcomes: An Umbrella Review of Meta-analysis of Randomized Controlled Trials

AIM

To grade the evidence from published meta-analyses of randomized controlled trials (RCTs) that assessed effects of pharmacist intervention on cardiovascular risk factors and cardiovascular outcomes.

METHODS

MEDLINE, Embase, and the Cochrane Library were searched from database inception to July 2021. Meta-analyses of RCTs were eligible. Quality of evidence were assessed by GRADE approach.

RESULTS

From 9,308 publications, 149 full-text articles were evaluated for eligibility, and 24 studies with 85 unique meta-analyses that assessed effects of pharmacist intervention on cardiovascular risk factors and cardiovascular outcomes. Overall, 71.7% (61/85) of unique meta-analyses showed significant impacts of pharmacist intervention. For the quality of evidence, 63.4% of meta-analyses had large heterogeneity (I² > 50%) while 1.2%, 16.5%, 32.9% and 49.4% of meta-analyses were graded as high, moderate, low and very low quality based on GRADE approach, respectively. Among meta-analyses with moderate quality, pharmacist interventions significantly mitigated risk factors (including 6/3 mmHg reduction of blood pressure, increased the rate of lipid control, glucose control and smoking cessation (pooled OR 1.91 (1.55, 2.35), 3.11 (2.3, 4.3), and 2.3 (1.33, 3.97), respectively)) and improved medication adherence (pooled OR 1.67 (1.38, 2.02)). Furthermore, pharmacist interventions significantly reduced all-cause mortality (pooled OR 0.72 (0.58, 0.89)) and improved quality of life in patients suffering from chronic heart failure.

CONCLUSION

This umbrella review found convincing evidence that pharmacist intervention can provide a wide range of benefits in cardiovascular disease management, ranging from risk factor control, improvement in medication adherence and in some setting, reduction in morbidity and mortality.

Interventions for Adherence Improvement in the Primary Prevention of Cardiovascular Diseases: Expert Consensus Statement

Over the last 2 decades, the management of chronic disease in Korea has been improved, but it has gradually stagnated. In order to improve care and reduce cardiovascular morbidity and mortality, it is crucial to improve primary prevention of cardiovascular diseases. In recent international guidelines for hypertension, diabetes, hyperlipidemia, obesity, and other conditions, adherence issues have become more frequently addressed. However, in terms of implementation in practice, separate approaches by dozens of related academic specialties need to be integrated into a systematic approach including clinician’s perspectives such as the science behind adherence, clinical skills, and interaction within team approach.

In primary prevention for cardiovascular diseases, there are significant barriers to adherence including freedom from symptoms, long latency for therapeutic benefits, life-long duration of treatment, and need for combined lifestyle changes. However, to implement more systematic approaches, the focus on adherence improvement needs to be shifted away from patient factors to the effects of the treatment team and healthcare system. In addition to conventional educational approaches, more patient-oriented approaches such as patient-centered clinical communication skills, counseling using motivational strategies, decision-making by patient empowerment, and a multi-disciplinary team approach should be developed and implemented. Patients should be involved in a program of self-monitoring, self-management, and active counseling. Because most effective interventions on adherence improvement demand greater resources, the health care system and educational or training system of physicians and healthcare staff need to be supported for systematic improvement.

A Critical Review of Medication Adherence in Hypertension: Barriers and Facilitators Clinicians Should Consider

Hypertension is a global public health problem, and its prevalence is increasing worldwide. Impacting all human societies and socioeconomic strata, it remains the major modifiable risk factor for global burden of cardiovascular disease all-cause mortality and the leading cause of loss of disability-adjusted life years. Despite increased awareness, the rate of blood pressure control remains unsatisfactory, particularly in low- to middle-income countries. Apparent treatment-resistant hypertension is associated with worse adverse health outcomes. It includes both true resistant and pseudo-resistant hypertension, which requires out-of-office blood pressure monitoring to exclude white-coat effect and confirmation of adherence to the agreed recommended antihypertensive therapy. The depth of medication non-adherence remains poorly recognized among medical practitioners, thus presenting an underestimated modifiable risk factor. Medication non-adherence is a complex and multidimensional variable with three quantifiable phases: initiation, implementation, and discontinuation, collectively called persistence. Non-adherence can be both intentional and non-intentional and usually involves several interconnected factors. Persistence declines over time in the treatment of chronic diseases like hypertension. The risk is higher in patients with new diagnosis, poor insurance status, polypharmacy, and multiple comorbidities, particularly psychiatric disorders. The World Health Organization divides the contributing factors impacting adherence into five categories. Screening and detection for medication non-adherence are challenging due to its dynamic nature and potential white-coat effect. Easy-to-conduct screening methods have low reliability and validity, whereas more reliable and valid methods are costly and difficult to perform. Medication non-adherence is associated with poor clinical outcome and potential negative impact on health-care costs. Evaluation of adherence should become an integral part of assessment of patients treated for hypertension. Medication adherence can significantly improve with a patient-centered approach, non-judgmental communication skills, and collaborative multidisciplinary management, including engagement of the patients in their care by self-blood pressure monitoring.

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.

Effects of Pharmacist Intervention on Community Control of Hypertension: A Randomized Controlled Trial in Zunyi, China

OBJECTIVE

We aimed to test the effects of pharmacist intervention on the community control of hypertension through a comparative randomized controlled trial.

METHODS

We recruited adult hypertensive patients with comorbidity or confusion with medication (n=636) from 2 community health centers in Zunyi, China. They were randomly and equally divided into 2 groups. Both groups received the usual care and participated in the community systematic management program of hypertension. Participants in the intervention group were given interventions from pharmacists, including a monthly review of medications, patient education, and medication adjustment advice to medical doctors over 6 months. Participants' blood pressure was assessed at baseline, 3 months, and 6 months. Participants' knowledge and medication adherence were measured using a questionnaire before and after the trial.

RESULTS

Compared to the control group (n=298), a significantly higher percentage of participants in the intervention group (n=290) had their blood pressure under control 3 months (46.9% vs. 38.3%, P=.034) and 6 months (60.7% vs. 40.9%, P<.001) after the interventions. Difference-in-differences analyses showed that the pharmacist intervention resulted in an increase in knowledge scores by 12.55 points (P<.001), a decrease in systolic blood pressure by 6.65 mmHg (P=.001), and a decrease in diastolic blood pressure by 7.26 mmHg (P<.001) compared to the controls after adjustment for variations in potential confounding factors. The odds of participants passing the hypertension knowledge tests in the intervention group was 4.45 times those in the control group (P<.001). Similarly, it was found that the intervention group had higher odds of not needing any medication adjustments (adjusted odds ratio [AOR]=2.75, P<.001) and having their blood pressure under control (AOR=2.18, P=.002) compared to the control group.

CONCLUSION

It is evident that pharmacist intervention has significant short-term effects on improving the knowledge and medication adherence of hypertensive patients, as well as timely medication adjustments from medical doctors, resulting in lowered blood pressure and an increased control rate. Further studies should explore the long-term sustainability of the effects of community pharmacist intervention.

Rationale and Design of a Pharmacist-led Intervention for the Risk-Based Prevention of Heart Failure: The FIT-HF Pilot Study

Background: Given rising morbidity, mortality, and costs due to heart failure (HF), new approaches for prevention are needed. A quantitative risk-based strategy, in line with established guidelines for atherosclerotic cardiovascular disease prevention, may efficiently select patients most likely to benefit from intensification of preventive care, but a risk-based strategy has not yet been applied to HF prevention. Methods and Results: The Feasibility of the Implementation of Tools for Heart Failure Risk Prediction (FIT-HF) pilot study will enroll 100 participants free of cardiovascular disease who receive primary care at a single integrated health system and have a 10-year predicted risk of HF of ≥5% based on the previously validated Pooled Cohort equations to Prevent Heart Failure. All participants will complete a health and lifestyle questionnaire and undergo cardiac biomarker (B-type natriuretic peptide [BNP] and high-sensitivity cardiac troponin I [hs-cTn]) and echocardiography screening at baseline and 1-year follow-up. Participants will be randomized 1:1 to either a pharmacist-led intervention or usual care for 1 year. Participants in the intervention arm will undergo consultation with a pharmacist operating under a collaborative practice agreement with a supervising cardiologist. The pharmacist will perform lifestyle counseling and recommend initiation or intensification of therapies to optimize risk factor (hypertension, diabetes, and cholesterol) management according to the most recent clinical practice guidelines. The primary outcome is change in BNP at 1-year, and secondary and exploratory outcomes include changes in hs-cTn, risk factor levels, and cardiac mechanics at follow-up. Feasibility will be examined by monitoring retention rates. Conclusions: The FIT-HF pilot study will offer insight into the feasibility of a strategy of quantitative risk-based enrollment into a pharmacist-led prevention program to reduce heart failure risk. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04684264.