The pharmacist and the management of arterial hypertension: the role of blood pressure monitoring and telemonitoring

Pharmacist Role in Hypertension Management in the Community Setting: Questionnaire Development, Validation, and Application

BACKGROUND

Hypertension is a leading cause of mortality and morbidity globally. Pharmacists can play a substantial role in decreasing the burden of the disease.

PURPOSE

The primary aim of this study was to develop and validate a scale assessing the pharmacist role in hypertension management in the community pharmacy setting. The secondary aims were to assess the services/interventions in hypertension management that were performed in the real-life setting, as well as the patient satisfaction from these services/interventions.

METHODS

This cross-sectional study was conducted in Egypt. The data were collected using a survey composed of three sections: a general section, the pharmacist role questionnaire section, and the patient satisfaction from the provided interventions/services section. The pharmacist role questionnaire was developed based on the pharmaceutical care practice conceptual model and included 23 questions. The face validity, content validity, reliability testing using Cronbach alpha, and construct validity using exploratory factor analysis were determined. The percentage of the frequency by which each role was reported to be performed was determined. Patient satisfaction from the provided interventions/services was determined by means of an overall rating. The correlation between practiced roles and patient satisfaction with received interventions/services was determined.

RESULTS

The questionnaire was valid with a 4-factor structure and a Cronbach alpha >0.75, reiterating the main pharmaceutical care practice domains: medication management, disease-state education, disease-state management, and care plan monitoring. Roles falling in the domains of disease state management and disease state education were significantly more practiced than roles falling in the other domains.

CONCLUSION

Pharmacist practice in hypertension management in the community setting was inclined towards contemporary roles, such as disease state education and management. Patients seem to be satisfied with these roles.

Evaluation of pharmacist-led telemedicine medication management for hypertension established patients during COVID-19 pandemic: A pilot study

Aim

To evaluate the impact of a telemedicine medication management service in patients with hypertension.

Methods

Participants were allocated to either a telemedicine service (N = 173) or usual care (UC) (N = 179). The primary outcome was blood pressure (BP) reduction from baseline to the 6-month follow-up visit, the proportion of the target BP achievement, overall adherence to prescribed medication as well as a composite of non-fatal stroke, non-fatal myocardial infarction and cardiovascular death.

Results

At 6 months, BP was controlled in 89.6% (n = 155) of intervention patients and 78.8% (n = 141) of UC patients (OR = 1.14, 95% CI = 1.04-1.25, P = 0.006), giving a mean difference of -6.0 (-13.0 to -2.5 mmHg) and -2.0 mmHg (-4.0 to -0.1 mmHg) in SBP and DBP, respectively. 17.9% (n = 31) of the patients in the intervention group were non-adherent with medications, compared with 29.1% (n = 52) in the UC group (P = 0.014). The composite clinical endpoints were reached by 2.9% in the intervention group and 4.5% in the control group with no significant differences (OR = 1.566, 95% CI = 0.528-4.646).

Conclusion

Telemedicine medication management for hypertension management had led to better BP control and medication adherence improvement than UC during COVID-19 epidemic, resulting in a reduction of overall adverse cardiovascular events occurrence.

TASC (Telehealth After Stroke Care): a study protocol for a randomized controlled feasibility trial of telehealth-enabled multidisciplinary stroke care in an underserved urban setting

Background

Hypertension is the most important modifiable risk factor for recurrent stroke, and blood pressure (BP) reduction is associated with decreased risk of stroke recurrence. However, hypertension remains poorly controlled in many stroke survivors. Black and Hispanic patients have a higher prevalence of uncontrolled BP and higher rates of stroke. Limited access to care contributes to challenges in post-stroke care. Telehealth After Stroke Care (TASC) is a telehealth intervention that integrates remote BP monitoring (RBPM) including nursing telephone support, tailored BP infographics and telehealth video visits with a multidisciplinary team approach including pharmacy to improve post-stroke care and reduce stroke disparities.

Methods

In this pilot trial, 50 acute stroke patients with hypertension will be screened for inclusion prior to hospital discharge and randomized to usual care or TASC. Usual care patients will be seen by a primary care nurse practitioner at 1–2 weeks and a stroke neurologist at 1 and 3 months. In addition to these usual care visits, TASC intervention patients will see a pharmacist at 4 and 8 weeks and will be enrolled in RBPM consisting of home BP monitoring with interval calls by a centralized team of telehealth nurses. As part of RBPM, TASC patients will be provided with a home BP monitoring device and electronic tablet that wirelessly transmits home BP data to the electronic health record. They will also receive tailored BP infographics that help explain their BP readings. The primary outcome will be feasibility including recruitment, adherence to at least one video visit and retention rates. The clinical outcome for consideration in a subsequent trial will be within-patient change in BP from baseline to 3 months after discharge. Secondary outcomes will be medication adherence self-efficacy and satisfaction with post-stroke telehealth, both measured at 3 months. Additional patient reported outcomes will include depression, cognitive function, and socioeconomic determinants. Multidisciplinary team competency and fidelity measures will also be assessed.

Conclusions

Integrated team-based interventions may improve BP control and reduce racial/ethnic disparities in post-stroke care. TASC is a post-acute stroke care model that is novel in providing RBPM with tailored infographics, and a multidisciplinary team approach including pharmacy. Our pilot will determine if such an approach is feasible and effective in enhancing post-stroke BP control and promoting self-efficacy.

Trial registration

ClinicalTrials.gov NCT04640519

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01025-z.

Investigating Pharmacists' Views on Telepharmacy: Prioritizing Key Relationships, Barriers, and Benefits

Background: Telepharmacy can help deliver pharmaceutical advice from an expert pharmacist to another party, such as a physician, inexperienced pharmacist, or pharmacy technician. In this study, we consider term "2-person discussions" as teleconsultation between expert pharmacists to each of the aforementioned persons. Objectives: This study has 2 aims: first to prioritize 2-person discussions between the parties involved in telepharmacy services when we have limited budget and time and would like to implement the best efficient telepharmacy system. Second to examine the barriers and benefits of implementing a telepharmacy. Methods: The research population included 40 pharmacists working in Kerman pharmacies (Iran). Their viewpoints were evaluated using a valid and reliable researcher-made questionnaire. The first part of the questionnaire focused on professional-demographic information, while the second part addressed the most important 2-person discussions and also asked about barriers to and benefits of implementing telepharmacy. Results: The findings indicate that the following 2-person discussions are priority for implementation: physician-pharmacist, pharmacist-hospital ward, and pharmacist-pharmacist. Payment and reimbursement issues and lack of access to information technology infrastructure were among the most important barriers. Efficient training about medicine usage, drug-drug interactions, and adverse effects was the most important benefit of telepharmacy. Conclusion: In this study, pharmacists' first priority regarding who to involve in a 2-person telepharmacy consultation was to establish a long-distance connection between physicians and pharmacists. This finding indicates that the pharmacists were more interested in providing teleconsultation services to physicians and other pharmacists rather than communicating with pharmaceutical technicians.

Home blood-pressure measurement for the diagnosis and monitoring of arterial hypertension by French general practitioners: a cross-sectional survey in the Auvergne region

Background

Home blood-pressure measurement (HBPM) is recommended for the diagnosis of hypertension and monitoring of patients with hypertension. Since 2013, the French National Health Insurance Body (FNHIB) has promoted HBPM to general practitioners (GPs). The objective of the study was to evaluate the practice of HBPM by French GPs to diagnose and monitor hypertension, 3 years after the beginning of the FNHIB campaign.

Methods

We conducted a postal survey from 7 March to 31 May 2016. All of the 1040 GPs practising in the Auvergne region in France were invited to participate, using a self-reporting questionnaire. We obtained information on the characteristics of the GPs, and their practice regarding the use of HBPM. Use of HBPM was reported as “never, occasionally, regularly and systematically”. Frequency of HBMP use was analysed using multivariate ordered logistic regression model.

Results

A total of 569 (54.7%) GPs responded to the survey. They were 50.3 (± 11.5) years old, 241 (43.0%) were female, and 352 (62.7%) worked in urban areas. Among them, 530 (94.5%) reported the use of HBPM for diagnosis and 519 (92.5%) for monitoring hypertension. To diagnose hypertension, younger GPs (OR = 0.97; 95% CI: 0.95–0.98), GPs practising in a group (OR = 1.45; 95% CI: 1.00–2.10) and in an MHC (OR = 2.09; 95% CI: 1.15–3.78), as compared to GPs with individual practices, and Clinical Tutors, as compared to non-Clinical Tutors, (OR = 1.92; 95% CI: 1.33–2.79) reported more frequent use of HBPM. To manage hypertension, female GPs, as compared to male GPs, (OR=1.47; 95% CI: 1.04–2.06), younger GPs (OR = 0.98; 95% CI: 0.97–0.99), and Clinical Tutors (OR = 1.90; 95% CI: 1.31–2.75) reported more frequent use of HBPM.

Conclusions

Our survey reveals that 3 years after the introduction of the FNHIB incentives, the use of HBPM by participating GPs to diagnose and manage hypertension is well established. A larger survey of GPs from other regions would make it possible to verify whether our results can be extrapolated to France as a whole.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-020-01358-9.

Telemedicine During the COVID-19 in Italy: A Missed Opportunity?

In the time of COVID-19 epidemic, Italy was found unprepared to manage lockdown patients with chronic diseases, due to limited availability and diffusion of large-scale telemedicine solutions. The scattered distribution and heterogeneity of available tools, the lack of integration with the electronic health record of the national health system, the poor interconnection between telemedicine services operating at different levels, the lack of a real multidisciplinary approach to the patient's management, the heavy privacy regulations, and lack of clear guidelines, together with the lack of reimbursement, all hinder the implementation of effective telemedicine solutions for long-term patients' management. This COVID-19 epidemic should help promote better use and a larger integration of telemedicine services in the armamentarium of health care services. Telemedicine must no longer be considered as an option or add-on to react to an emergency.

Pharmacist Interventions in the Management of Blood Pressure Control and Adherence to Antihypertensive Medications: A Systematic Review of Randomized Controlled Trials

OBJECTIVE

Pharmacists are ideally positioned to promote optimal use and assess the adherence of prescription medications in patients with chronic diseases. This systematic review of randomized controlled trials (RCTs) ascertains the effectiveness of pharmacist interventions to improve blood pressure (BP) control and medication adherence in patients with hypertension.

DATA SOURCES

Electronic databases were searched for studies in English published between January 1, 1995, and January 31, 2018. Eligibility criteria included patients with a diagnosis of hypertension tested with RCT where pharmacist-led interventions occurred. The primary outcome was BP control and the secondary outcome was adherence to hypertensive medication. Quality of studies was assessed using the Cochrane Risk of Bias Tool.

DATA SYNTHESIS

Thirty-five studies met the inclusion-exclusion criteria and were included in this study. Major themes included pharmacist-led interventions with medication counseling, patient education, distribution of interventions materials, individualized care plans, and check-in meetings. The vast majority of trials (n = 29) showed statistically significant improvement in BP in the intervention groups at follow-up. Of the 35 studies, most (n = 20) assessed medication adherence; several trials (n = 9) showed statistically significant improvement in medication adherence in patients receiving additional pharmaceutical care services. None of the RCTs was considered to have a high risk of bias.

CONCLUSION

Pharmacist-led interventions improved BP control and medication adherence through education, counseling, or a combination of both. Future research is needed to determine the most effective pharmacists' interventions in managing hypertension and to assess the cost-effectiveness of these interventions.

Telemonitoring and remote counseling in hypertensive patients. Looking for new ways to do old jobs

XXI century emphasized humanity to embrace the digital era after a reality of Third and Fourth Industrial Revolutions, nowadays dictating new terms of social networking. It is expected that information and communication technologies integrated with value-based medicine will significantly impact healthcare delivery to tremendous number of patients with socially important noncommunicable diseases. Cardiovascular illnesses comprise the greatest part of such pathologies. Hypertension (HTN) being the most prevalent cardiovascular disease is also the key modifiable cardiovascular risk factor yet seems to be an attractive target for both value-based concept and telehealth interventions. Present review addresses up-to-date science on telehealth, sets out the main well-known, but yet unsolved challenges in management of HTN along with the new approaches involving telemedicine programs, digital health outlooks. The main barriers of telehealth implementation are also considered along with the possible solutions.

The Effect of Health Education by Pharmacists on 10-Year Atherosclerotic Cardiovascular Disease Risk: A Cluster-Randomized Control Study in a Low Socioeconomic Status Javanese Population

BACKGROUND

Evidence from previous studies demonstrates that lifestyle modification reduces the incidence and complications of atherosclerotic cardiovascular disease. The study aimed to investigate the effect of a lifestyle intervention provided by pharmacists on the 10-year atherosclerotic cardiovascular disease (ASCVD) risk and quality of life (QoL) in a low socioeconomic status Javanese population.

METHODS

This research was a cluster-randomized controlled study of 1-year duration, conducted in a lower social economic community in the Sleman District of Yogyakarta, Indonesia. The eligible subjects were dichotomized into 2 groups: 40 to 55 years (n = 61 vs 65) and 56 to 70 years (n = 21 vs 43) for intervention and control subjects, respectively. The ASCVD score and risk factors within the age-based groups were analyzed using T test/Mann-Whitney test for continuous data or chi-square test for categorical data.

RESULTS

The intervention and control subjects had similar baseline characteristics ( P > .05), including the ASCVD risk with the low- and high-risk classification for younger and elder subjects, respectively. At final follow-up, the younger intervention subjects had lower 10-year ASCVD risk ( P = .001), higher high-density lipoprotein cholesterol ( P = .02), smoking status ( P = .001), persistence rate ( P = .03), and QoL value for the physical and social function domains ( P < .05) than the control subjects, whereas the elder intervention subjects only had better ASCVD risk score than controls ( P = .03). Smoking interacting with intervention was the most influential variable on ASCVD risk in logistic regression analysis.

CONCLUSION

The study demonstrates that the health education by the pharmacists produce significant outcomes of the ASCVD risk, smoking status, and QoL of physical and social function particularly in the younger group.

Telemonitoring of 24-Hour Blood Pressure in Local Pharmacies and Blood Pressure Control in the Community: The Templar Project

BACKGROUND

The analysis of ambulatory blood pressure monitorings (ABPMs) performed in 639 Italian pharmacies in the context of a telehealth-based service allowed to evaluate the level of blood pressure (BP) control in the community.

METHODS

Twenty-four-hour ABPMs were performed by a clinically validated, automated, upper-arm BP monitor. Recordings were uploaded on a certified web-based telemedicine platform (www.tholomeus.net) and remote medical reporting provided. In each subject, an automatic BP measurement was obtained in the pharmacy and clinical information collected before starting the ABPM.

RESULTS

A total of 20,773 subjects (mean age 57 ± 15 years; 54% females; 28% receiving antihypertensive medications, 31% with any cardiovascular [CV] risk factor) provided valid ABPMs. BP control was poor, but better in ambulatory conditions (24-hour BP <130/80 mm Hg 54% vs. pharmacy BP < 140/90 mm Hg 43%; P < 0.0001) and in drug-treated subjects. Sustained normotension was reported in only 28% subjects. Isolated nocturnal hypertension (16%; nighttime BP ≥120/70 mm Hg with normal daytime BP) was more common (P < 0.0001) than isolated daytime hypertension (9%; daytime BP ≥ 135/85 mm Hg with normal nighttime BP). Sustained hypertension (43%) was more common in younger males at the lowest CV risk, with daytime hypertension. White-coat hypertension (14%) was more common in females. Masked hypertension was not uncommon (15%) and more often observed in older males with an elevated nocturnal BP.

CONCLUSIONS

A telemedicine-based service provided to community pharmacies may facilitate access to ABPM, thus favoring a more accurate hypertension screening and detection. It may also help describe the occurrence of different 24-hour BP phenotypes and personalize the physician's intervention.

Physician-pharmacist collaborative practice and telehealth may transform hypertension management

Community pharmacists play a crucial role in hypertension management and their intervention, mainly including education, medication monitoring, and reviewing, blood pressure (BP) measurement and cardiovascular risk factors tracking, have proved to enhance BP control and adherence to antihypertensive treatment. A multidisciplinary collaborative approach with the referring physician and a patient-centered model of care have been proved to be particularly effective for improving control of hypertension and promoting patients' health. The inclusion of telehealth in such model (the so-called telepharmacy) may expand the reach of the pharmacist's intervention and provide pharmacy operations and patient care at a distance with further benefits for hypertensive patients and their managing physicians. Very few randomized controlled studies have evaluated the clinical efficacy of the implementation of telepharmacy services in the management of hypertension, with the strongest evidence limited to physician-pharmacist collaborative interventions based on home BP telemonitoring plus patient education on lifestyle, drug therapy, and cardiovascular risk factors control. The results of these trials documented a benefit of telehealth mainly in terms of improvement of BP control consequent to antihypertensive medication intensification and optimization. Although promising, these results need to be corroborated through larger, prospective, and long-term studies, which should also evaluate additional long-term benefits of telepharmacy services in hypertension management.

Home sphygmomanometers can help in the control of blood pressure: a nationwide field survey

Home blood pressure monitoring (HBPM), which integrates patients into their treatment program, is a self-management tool. The prevalence of home sphygmomanometer ownership and patient compliance with HBPM guidelines are not well known, especially in developing and underdeveloped countries. The aims of this study were to measure the prevalence of home sphygmomanometer ownership among hypertensive subjects through a nationwide field survey (PatenT2), to investigate the validation of sphygmomanometers and consistency of the user arm circumference and cuff size of the upper-arm device owned, as well as to compare blood pressure (BP) readings between hypertensive subjects who have or do not have a sphygmomanometer. Sample selection was based on a multistratified proportional sampling procedure to select a nationally representative sample of the adult population (n = 5437). Of 1650 hypertensive subjects, 332 (20.1%) owned a device, but the percentage of patients who owned a sphygmomanometer was 28.8% among patients who were aware of their hypertension (260/902). The usage of wrist devices and nonvalidated devices is common, and selection of an appropriate cuff size is ignored. Linear-regression analysis showed that owning a BP monitor is associated with decreases of 3.7 mmHg and 2.8 mmHg for systolic and diastolic BPs, respectively. Many patients do not own a sphygmomanometer. The decrease of systolic and diastolic BPs among BP monitor owners is a striking finding. The implementation of a hypertension care program consisting of sphygmomanometer reimbursement and training of patients in its use for HBPM might be cost-effective.

Effectiveness of pharmacist's intervention in the management of cardiovascular diseases

The pharmacist may play a relevant role in primary and secondary prevention of cardiovascular diseases, mainly through patient education and counselling, drug safety management, medication review, monitoring and reconciliation, detection and control of specific cardiovascular risk factors (eg, blood pressure, blood glucose, serum lipids) and clinical outcomes. Systematic reviews of randomised controlled and observational studies have documented an improved control of hypertension, dyslipidaemia or diabetes, smoking cessation and reduced hospitalisation in patients with heart failure, following a pharmacist’s intervention. Limited proof for effectiveness is available for humanistic (patient satisfaction, adherence and knowledge) and economic outcomes. A multidisciplinary approach, including medical input plus a pharmacist, specialist nurse or both, and a greater involvement of community rather than hospital pharmacists, seems to represent the most efficient and modern healthcare delivery model. However, further well-designed research is demanded in order to quantitatively and qualitatively evaluate the impact of pharmacist’s interventions on cardiovascular disease and to identify specific areas of impact of collaborative practice. Such research should particularly focus on the demonstration of a sensitivity to community pharmacist’s intervention. Since pharmacy services are easily accessible and widely distributed in the community setting, a maximum benefit should be expected from interventions provided in this context.

A coordinated PCP-Cardiologist Telemedicine Model (PCTM) in China's community hypertension care: study protocol for a randomized controlled trial

BACKGROUND

Hypertension is a major risk factor for cardiovascular disease, and its control rate has remained low worldwide. Studies have found that telemonitoring blood pressure (BP) helped control hypertension in randomized controlled trials. However, little is known about its effect in a structured primary care model in which primary care physicians (PCPs) are partnering with cardiology specialists in electronic healthcare data sharing and medical interventions. This study aims to identify the effects of a coordinated PCP-cardiologist model that applies telemedicine tools to facilitate community hypertension control in China.

METHODS/DESIGN

Patients with hypertension receiving care at four community healthcare centers that are academically affiliated to Shanghai Chest Hospital, Shanghai JiaoTong University are eligible if they have had uncontrolled BP in the previous 3 months and access to mobile Internet. Study subjects are randomly assigned to three interventional groups: (1) usual care; (2) home-based BP telemonitor with embedded Global System for Mobile Communications (GSM) module and unlimited data plan, an app to access personal healthcare record and receive personalized lifestyle coaching contents, and proficiency training of their use; or (3) this plus coordinated PCP-cardiologist care in which PCPs and cardiologists share data via a secure CareLinker website to determine interventional approaches. The primary outcome is mean change in systolic blood pressure over a 12-month period. Secondary outcomes are changes of diastolic blood pressure, HbA1C, blood lipids, and medication adherence measured by the eight-item Morisky Medication Adherence Scale.

DISCUSSION

This study will determine whether a coordinated PCP-Cardiologist Telemedicine Model that incorporates the latest telemedicine technologies will improve hypertension care. Success of the model would help streamline the present community healthcare processes and impact a greater number of patients with uncontrolled hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02919033 . Registered on 23 September 2016.

Telemedicine and M-Health in Hypertension Management: Technologies, Applications and Clinical Evidence

Electronic processes and communication technologies are more and more often employed to provide healthcare services to caregivers and their patients. Such solutions are currently referred as e-health, the most popular and widely distributed being those based on telemedicine and mobile health (m-health). A specific application of telemedicine for hypertension management is blood pressure telemonitoring (BPT), which allows remote data transmission of BP and additional information on patients' health status from their living site or from a community setting to the doctor's office or the hospital. Several randomized studies have documented a significant BP reduction with regular BPT compared to usual care, particularly in high risk hypertensive patients. Additional benefits are observed when BPT is offered under the supervision of a team of healthcare professionals, including a community pharmacist. BPT may also be provided in the context of m-health solutions, which commonly include wireless diagnostic and clinical decision support tools. M-health has the potential to promote patient's self-management, as a complement to the doctor's intervention, and encourage greater participation in medical decision making. Current statistics show that half of smartphone owners gather health information through their phone and 19 % use a health app. In case of hypertensive patients the most popular apps are those with tracking function, including BPT. Thus, e-health, and in particular BPT and m-health, are progressively gaining a key role in the management of hypertensive patients, having the potential to improve the quality of the delivered care and to more effectively prevent cardiovascular consequences of high BP.