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Service Delivery Innovation Profile

Pharmacists Monitor Hypertensive Patients and Make Recommendations to Physicians, Leading to Better Blood Pressure Control and Increased Physician Adherence to Established Guidelines


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Snapshot

Summary

Clinical pharmacists collaborated with physicians to manage patients with uncontrolled high blood pressure at six family practice clinics. Pharmacists assessed the causes of the patient's poor blood pressure control, developed a guideline-based treatment plan, monitored the patient's treatment response at regular intervals, and made recommendations as necessary to the treating physician for medication adjustments designed to achieve good blood pressure control. The 6-month program improved blood pressure control, even in hard-to-treat patients with diabetes, and increased physician adherence to established treatment guidelines for hypertension. It had no impact on patient adherence to the prescribed regimen.

Evidence Rating (What is this?)

Strong: The evidence consists of a prospective, cluster randomized controlled trial at six community-based family medicine residency programs that measured pre- and post-implementation blood pressure levels, degree of adherence to established treatment guidelines, and self-reported patient adherence to the prescribed regimen.
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Developing Organizations

University of Iowa College of Medicine; University of Iowa College of Pharmacy; University of Iowa College of Public Health
Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowaend do

Date First Implemented

2005
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Patient Population

The program served patients with uncontrolled hypertension treated at six community-based family medicine residency programs in Iowa; the average age was 58 years old, with 63.5 percent being female and 86 percent being white.end pp

Problem Addressed

Hypertension affects more than one in four Americans. Despite the availability of safe and effective blood pressure medications, many individuals with hypertension receive ineffective treatment and hence continue to have elevated blood pressure, increasing the risk of heart attacks, strokes, and other cardiovascular problems.
  • Widespread and poorly controlled: An estimated 28 percent of adults age 20 and older have high blood pressure, with only 18 percent of them having it under control as a result of diet, exercise, or treatment.1 At six community family practice clinics in Iowa, for example, the percentage of patients being treated for hypertension who had their blood pressure under control ranged from 28.6 to 70 percent.2
  • Inadequate treatment: Although many doctors assume poor medication adherence is behind uncontrolled hypertension in patients, studies show that doctors often fail to follow hypertension treatment guidelines and intensify treatment—increasing dosages or adding new drugs—when patients have uncontrolled hypertension.3 As a result of suboptimal treatment, hypertension is controlled in only 37 percent of the 65 million Americans with this condition.3
  • Pharmacists are underutilized in blood pressure treatment but can play vital role: Health care providers rarely include clinical pharmacists on their health care teams when treating patients with hypertension. Many practices lack onsite clinical pharmacists, and most health insurance plans do not cover pharmacist services in treatment of hypertension. The pharmacist is uniquely positioned to improve blood pressure control by addressing medication-related problems, including recommending optimal drug treatment. Studies within integrated health systems have demonstrated that when pharmacists are included in health care teams, hypertension control rates increase and drug interactions, poor patient adherence, and health care costs are reduced.4

What They Did

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Description of the Innovative Activity

Clinical pharmacists, who worked alongside physicians in six family practice clinics, collaborated with the physicians to manage patients with uncontrolled high blood pressure. Pharmacists assessed the causes of the patient's poor blood pressure control, developed a guideline-based treatment plan, monitored the patient's treatment response at regular intervals, and made recommendations as necessary to the treating physician for medication adjustments designed to achieve good blood pressure control. Key elements of the program include the following:
  • Creation of pharmacist–physician team: Physicians met with trained pharmacists several times, often over lunch with a facilitator, to define how they would interact as a team. (See the Planning and Development Process section for details on training.) Because pharmacists and physicians already had working relationships—primarily in teaching capacities—these team-building efforts focused on how to work together to care for hypertension. Discussions often centered on how much pharmacist input the physician felt comfortable with receiving, and how the physician wanted to work with the pharmacist. (Pharmacist–physician teams were free to create their own working arrangements.) These sessions also explored strategies to assess and address treatment failures, poor medication adherence, potential adverse reactions, drug interactions, and other barriers to success. The teams agreed that, in the case of a disagreement, physicians would make the final decision.
  • Pharmacist screening of patients: Pharmacists took a complete medical history of each patient to determine why blood pressure was not being adequately controlled; potential reasons could include poor medication adherence, inability to afford medications, inappropriate medications, and other factors. This screening session typically took between 45 minutes and an hour.
  • Pharmacist-crafted treatment plans: Pharmacists crafted treatment plans with blood pressure goals. Often these plans involved multiple medication changes. In fact, the average pharmacist plan recommended 3.6 medication changes, with 49.3 percent of these being new medications, 29.2 percent being dosage increases, 17.1 percent being the discontinuation of current medications, and 4.3 percent being dosage declines. For example, pharmacists often suggested adding thiazide diuretics if not in the regimen, increasing medication doses to at least moderate levels, using combinations of medications based on pharmacology, and adding medications to treat coexisting conditions when appropriate (e.g., angiotensin-converting enzyme inhibitors for patients with diabetes). The pharmacists typically made recommendations to physicians in a face-to-face meeting, explaining how the current treatment plan compares with national clinical guidelines.
  • Physician review and acceptance/rejection: Physicians retained final authority to accept or reject the pharmacists' recommendation. In practice, physicians accepted nearly all (96 percent) pharmacist recommendations.
  • Ongoing monitoring, additional recommendations as necessary: The pharmacist reviewed the patient's response to the treatment plan by telephone 1 to 2 weeks after the initial assessment, and then every 1 to 2 months either in person or by telephone. During the study, pharmacists typically met by phone or in person with patients four to six times, usually for approximately 15 minutes at a time. If the pharmacist determined that patients were not adequately responding to the current regimen, they made recommendations for additional changes to the treating physicians.

Context of the Innovation

The Department of Pharmacy Practice and Science at the University of Iowa College of Pharmacy offers graduate education in clinical pharmaceutical sciences, including a variety of research opportunities to study pharmaceutical care in the ambulatory environment. Researchers from the university's pharmacy, medical, and public health schools have been studying how multidisciplinary team-based care improves health care delivery for several years in several Iowa City area clinics. While multiple studies by other researchers have shown that partnerships between physicians and nurses and/or pharmacists can improve blood pressure control, no comprehensive study had been conducted on the effectiveness of teams of onsite clinical pharmacists and family practice physicians.

Did It Work?

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Results

The program improved blood pressure control, even in hard-to-treat patients with diabetes, and increased physician adherence to established treatment guidelines for hypertension; it had no impact on patient adherence to the prescribed regimen.
  • More medication changes: Participating patients had an average of 3.6 medication changes over a 6-month period, well above the 2.2 average changes made by the treating physician for those in the control group.
  • Better blood pressure control: Sixty-four percent of those participating in the program got their blood pressure under control, compared with just 29.9 percent of patients in a control group receiving usual care, according to blood pressure tests conducted during office visits. The average decline was 20.7/9.7 mm Hg among participants, much more than the 6.8/4.5 mm Hg decline in the control group. Blood pressure readings taken by a monitoring device over a 24-hour period showed similar changes.
  • Even for hard-to-treat hypertensive patients with diabetes: Among hypertensive patients with diabetes, 45.5 percent in the intervention group achieved adequate blood pressure control, compared with just 26.1 percent of diabetic patients in the control group.
  • Greater adherence to treatment guidelines: After 6 months, physician adherence to clinical treatment guidelines increased by 55.4 percent among program participants, well above the 8.1 percent increase in the control group.
  • No impact on patient medication adherence: The program had little impact on patient medication noncompliance. Among program participants, patient medication noncompliance fell from 17.3 percent to 14.6 percent, while noncompliance in the control group similarly declined, from 18.7 percent to 14.7 percent.

Evidence Rating (What is this?)

Strong: The evidence consists of a prospective, cluster randomized controlled trial at six community-based family medicine residency programs that measured pre- and post-implementation blood pressure levels, degree of adherence to established treatment guidelines, and self-reported patient adherence to the prescribed regimen.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Recruiting doctors: University of Iowa researchers recruited university-affiliated teaching physicians from community-based family medicine residency clinics. After the institutional review boards of the clinics approved the study, researchers promoted the collaboration to physicians by emphasizing its ability to benefit both patients and physicians. Physician participation was voluntary.
  • Recruiting patients: A research nurse employed by each clinic contacted patients of participating physicians taking antihypertensive medications who had not achieved adequate blood pressure control. The nurses offered these patients $100 to participate, with the money covering the cost of their time to attend additional office visits and participate in monitoring.
  • Training pharmacists on expanded role and on hypertension: The clinical pharmacists received two 90-minute training sessions on hypertension medication and treatment to ensure consistent treatment that mirrored clinical treatment guidelines. The training also helped prepare them to take a more active, direct role with the patient, something that historically had not been a major part of their responsibilities.

Resources Used and Skills Needed

  • Staffing: The program requires dedicated clinical pharmacist time; physicians participate as part of their regular duties. Managing 80 patients requires roughly 10 percent of a full-time clinical pharmacist's time. The clinical pharmacists participating in the study had doctorates of pharmacy and had completed a clinical pharmacy residency or fellowship in primary care.
  • Costs: Data on program costs are unavailable, but consist primarily of the costs of the clinical pharmacists' time.
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Funding Sources

Agency for Healthcare Research and Quality; National Heart, Lung, and Blood Institute (U.S.); National Institutes of Health
The National Heart, Lung, and Blood Institute provided a $1.9 million, 3-year grant to fund research costs associated with the study. At five of the six participating clinics, the costs of the clinical pharmacists were shared evenly by the medical office that provides family medicine physician resident education and patient care, and by the University of Iowa’s College of Pharmacy. Other research funds came from the Agency for Healthcare Research and Quality Centers for Education and Research on Therapeutics (5U18 HS016094), and from the Center for Research in Implementation in Innovation Strategies in Practice within the U.S. Department of Veterans Affairs.end fs

Tools and Other Resources

National Heart, Lung, and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - Complete Report. December. 2003. Available at: http://www.nhlbi.nih.gov/guidelines/hypertension

AACE Guidelines: American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Hypertension. Endocr Pract. 2006;12(2). Available at: http://www.aace.com/files/hypertension-guidelines.pdf

Guideline Central. Hypertension guidelines. Kaiser Permanente Care Management Institute. Hypertension guidelines. Oakland (CA): Kaiser Permanente Care Management Institute. June 2005. Available at: http://www.guidelinecentral.com/_webapp_1825764/Hypertension_guidelines

A related University of Iowa video segment was played on the Big Ten television network: http://www.youtube.com/watch?v=nhUZGnpY6jk/

Adoption Considerations

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Getting Started with This Innovation

  • Identify ways to reach target population: Identify primary care practices and other health care organizations or systems serving adults with uncontrolled hypertension.
  • Establish relationship with clinical pharmacists: Collaborate with an onsite or consulting clinical pharmacist, or identify a credentialed community pharmacist who would be acceptable to the collaborating physicians.
  • Promote benefits to secure buy-in: Have a respected stakeholder, such as a clinical director, share data on current lack of adherence to hypertension practice guidelines and on the potential of the program to improve blood pressure control.
  • Allow flexibility: Create team-building opportunities between providers and pharmacists, and allow physicians to define their working relationship with the pharmacists as they see fit.

Sustaining This Innovation

  • Track and report on improvements: Monitor trends in blood pressure control and adherence to clinical guidelines, thus documenting the value of the program. Share results with participating clinicians.
  • Make case for insurance coverage: Because most private insurance plans do not pay for clinical pharmacist monitoring and consultations with physicians, consider sharing data on the program's potential cost savings with the leaders of these plans in an effort to demonstrate the potential benefits of covering such services.

Additional Considerations

  • Consider nurse–pharmacist–physician teams: Researchers believe that the addition of a nurse to the physician–pharmacist team could prove to be very effective. The pharmacists would adjust medications until blood pressure is controlled, and the nurse would serve as an ongoing care manager and provide counseling about lifestyle issues and diet. The pharmacist could be brought back in if problems with blood pressure control resurface.
  • Consider use in other populations: Studies have shown that having clinical pharmacists participate as part of care teams can help to improve treatment for diabetes and other chronic diseases that require aggressive treatment and long-term monitoring.

More Information

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Contact the Innovator

Barry L. Carter, PharmD
Professor, Department of Pharmacy Practice and Science
College of Pharmacy
University of Iowa
115 South Grand Ave.
Iowa City, IA 52242
Phone: (319) 335.8456
Fax: (319) 353.5646
E-mail: barry-carter@uiowa.edu

Innovator Disclosures

Dr. Carter reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.

References/Related Articles

Carter B, Ardery G, Dawson J, et al. Physician and pharmacist collaboration to improve blood pressure control. Arch Intern Med. 2009;169(21):1996-2002. [PubMed]

Carter B, Bergus G, Dawson J, et al. A cluster randomized trial to evaluate physician/pharmacist collaboration to improve blood pressure control. J Clin Hypertens (Greenwich). 2008;10(4):260-71. [PubMed]

Carter B, Zillich A, Elliott W. How pharmacists can assist physicians with controlling blood pressure. J Clin Hypertens (Greenwich). 2003;5(1):31-7. [PubMed]

Carter B, Rogers M, Daly J, et al. The potency of team-based care interventions for hypertension: a meta-analysis. Arch Intern Med. 2009;169(19):1748-55. [PubMed]

Carter B, Clarke W, Ardery G, et al. A cluster-randomized effectiveness trail of a physician-pharmacist collaborative model to improve blood pressure control. Circ Cardiovasc Qual Outcomes. 2010 Jul;3(4):418-23. [PubMed] Available at: http://circoutcomes.ahajournals.org/content/3/4/418.abstract

(Added May 2013) Chen Z, Ernst MD, Ardery G, Xu Y, Carter BL. Physician-pharmacist co-management and 24-hour blood pressure control. J Clin Hypertens, in press.

Kulchaitanaroaj P, Brooks, J, et al. Incremental Costs Associated with Physician and Pharmacist Collaboration to Improve Blood Pressure Control. Pharmacotherapy. 2012;32:772-780. [PubMed]

(Added May 2013) Wentzlaff DM, Carter BL, Ardery G, Franciscus CL, Doucette WR, Chrischilles EA, Rosenkrans KA, Buys LM. Sustained blood pressure control following discontinuation of a pharmacist intervention. Journal of Clinical Hypertension 2011:13:431-437. [PubMed]

Footnotes

1 Centers for Disease Control and Prevention, National Institutes of Health. Health People 2010. 12: Heart Disease and Stroke. Available at: http://www.cdc.gov/dhdsp/docs/hp2010.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 Carter B, Ardery G, Dawson J, et al. Physician and pharmacist collaboration to improve blood pressure control. Arch Intern Med. 2009;169(21):1996-2002. [PubMed]
3 Carter B, Bergus G, Dawson J, et al. A cluster randomized trial to evaluate physician/pharmacist collaboration to improve blood pressure control. J Clin Hypertens (Greenwich). 2008;10(4):260-71. [PubMed]
4 Carter B, Zillich A, Elliott W. How pharmacists can assist physicians with controlling blood pressure. J Clin Hypertens (Greenwich). 2003;5(1):31-7. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 09, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 05, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 06, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.