Evidence is mounting for pharmacists’ ability to lower patients’ blood pressure—and save the health care system money

On The Cover

Loren Bonner and Olivia C. Welter, PharmD

An economic analysis published November 3, 2023, in JAMA Network Open finds that with pharmacist-led interventions, 15 million heart attacks could be prevented for Americans as well as over a trillion dollars in savings for the health care system over 30 years.

The $1.1 trillion in health care savings over 30 years, or a cost savings of $10,162 per patient, stems from preventive measures such as pharmacists educating patients on high BP and prescribing antihypertensive medication as well as helping patients better manage their BP. Pharmacists ability to offer these services could mean a reduction in CV emergencies, which is crucial given the increasing mortality rates around hypertension.

CDC data find that over half of all individuals with high BP don’t have it under control. Hypertension affects over 100 million Americans and is one of the leading causes of heart disease and kidney failure in the world.

According to the economic analysis, in over 30 years, patients could regain more than 30 million “quality-adjusted life years,” or years in which their quality of life is significantly higher than it would have been if they were to have a health emergency. The analysis was based on data from the RxACTION trial, which spanned from 2009 to 2013.

“Our data combined with existing data found that pharmacist-led models of care do have significant economic value not just in providing BP control, but for cholesterol, A1C, and more,” said lead study author Dave Dixon, PharmD, chair of the Department of Pharmacotherapy and Outcomes Science at Virginia Commonwealth University School of Pharmacy. “We consistently see that these models are cost-effective, too.”

The growing body of research includes the landmark Los Angeles Barbershop Blood Pressure study published in NEJM in 2018. Researchers found that with the help of pharmacists who provided hypertension education, medication management, and lifestyle recommendations in barbershops, Black male barbershop patrons had a greater BP reduction. Their systolic BP dropped by about 22 mm Hg more than it did for men in the control group, who only received health information from their barber.

A 2021 follow-up study published in Circulation found that the barbershop intervention was also cost-effective, especially when pharmacists used generic BP medications.

Dixon said what makes their JAMA Network Open study unique is that they used data from randomized controlled trials where pharmacists prescribed antihypertensive therapy.

They built in $100 for the initial visit for prescribing and when adding that into the model it was still cost-effective, according to Dixon.

All 50 U.S. states plus Washington, DC, give pharmacists prescriptive authority in collaboration with physicians. However, even though the United States has all the tools and resources to put pharmacist-prescribing interventions in place, there is still no reimbursement for pharmacists to be paid for their clinical services. The study provides data on the economics of pharmacist prescribing to improve BP control.

Dixon and fellow researchers also found that if pharmacists had a larger role in prescribing medications to
control BP, they could prevent more than 15 million heart attacks, nearly 8 million strokes, and more than 4 million cases each of angina and heart failure in the United States over 30 years.

Dixon said this specific evidence could be helpful for policymakers who are trying to advance scope of practice or reimbursement for pharmacist services as well as for health systems and pharmacists in community practice.

“This is ultimately providing evidence,” said Dixon.

Marginalized populations

According to Dixon, pharmacists’ services could also close gaps in poor outcomes for racial and ethnic minority groups. Black patients aged 35 to 64 years have the highest rates of death due to hypertension of any racial or ethnic group in the United States, according to a 2020 study in the journal Hypertension.

“Pharmacist-led interventions have been shown to significantly improve BP control among Black individuals and individuals of racial and ethnic minoritized groups,” wrote Dixon and study authors in their paper.

A study published in JAPhA on November 21, 2023, found that pharmacist-led interventions resulted in clinically and statistically significant improvements in sustained uncontrolled BP among minority populations.

“The most striking finding was how many more patients reached a BP of less than 140/90 mm Hg with a pharmacist involved in care compared to care without a pharmacist,” said lead author Luis Trejo, PharmD, from Atrium Health Cabarrus in Concord, NC. “I was certainly expecting higher control with a pharmacist involved, but it was surprising to see that more than twice as many patients in the pharmacist-involved group reached a BP of less than 140/90 mm Hg compared to the control group.”

The study included 110 patients from Atrium Health Concord Internal Medicine, a large suburban practice in Concord, NC. Patients with uncontrolled hypertension were identified using an EHR data tool. Patients were included if they were at least 18 years old, had sustained uncontrolled hypertension, and were of a minority race or ethnicity. Most patients enrolled in the study were female and Black.

In the intervention group, 70.9% of the patients achieved a BP of less than 140/90 mm Hg compared with 32.7% of the patients in the control group. The most common intervention was lifestyle modifications, followed by BP monitoring technique education, and medication adherence interventions.

“This study showcases that utilizing EHR reports to identify populations with disparities and uncontrolled hypertension is a viable strategy to increase health equity,” Trejo said.

He added that he was struck by the high rates of low health literacy regarding hypertension and antihypertensive medications.

“I found myself spending a lot of time during initial visits providing general education on hypertension, including the chronic nature of the disease state, BP goals, and how to appropriately monitor BP at home [as well as] potential complications of uncontrolled hypertension, lifestyle modifications to help lower BP, and education on their antihypertensives, including how they work and potential side effects,” said Trejo.

Although the study design was limited by its relatively small sample size and the single-center design, Trejo said the findings are reliable given the objective outcomes measured. They are also consistent with previous studies—including the Los Angeles Barbershop Blood Pressure study—showing improved BP control when pharmacists were involved, especially for minority populations.

CDC resources for hypertension management

• CDC’s Division for Heart Disease and Stroke Prevention Best Practices Guide and Clearinghouse (https://hdsbpc.cdc.gov/s/) highlights four strategies that directly engage pharmacists within the Leveraging Community and Clinical Public Health Workforce approach. Pharmacists may be able to implement or support implementation of other strategies included in the guide.
• Pharmacists interested in developing services to support hypertension management can read Using the Pharmacists’ Patient Care Process to Manage High Blood Pressure: A Resource Guide for Pharmacists (www.cdc.gov/dhdsp/pubs/docs/pharmacist-resource-guide.pdf).
• Pharmacists, health care professionals, and their partners interested in designing and implementing a hypertension pharmacists program can use the Pharmacists’ Patient Care Process Approach Guide (www.cdc.gov/dhdsp/evaluation_resources/guides/pharmacists_patient_care.htm).
• Pharmacists, health care professionals, and their partners interested in improving outpatient hypertension programs can use the Million Hearts Hypertension Control Change Package (https://millionhearts.hhs.gov/tools-protocols/action-guides/htn-change-package/index.html).
• Pharmacists, health care professionals, and their partners interested in incorporating health equity metrics and processes into strategic planning, implementation, and evaluation can use the Health Equity Indicators Toolkit (www.cdc.gov/dhdsp/health_equity/index.htm).

Guidelines with pharmacists on the team

Earlier this year, the Community Preventive Services Task Force (CPSTF), which complements the work of the U.S. Preventive Services Task Force, released an updated review in which they recommended team-based care to improve BP control. Teams that included pharmacists produced the greatest reduction in systolic BP and at the lowest cost per unit reduction, they found, followed by teams that included nurses.

The CPSTF findings are based on updated evidence from a systematic review of 54 studies conducted from 2012 through 2020.

In 39 of the studies, team-based care increased the proportion of patients with controlled BP by a median of 8.5%. In 44 studies, BP measurements were reduced by a median of 3.5 mm Hg.

CPSTF also found that the team-based approach is cost-effective. A systematic review of economic evidence from 35 studies showed team-based care interventions to improve BP control are cost-effective.

In 2017, pharmacists were specifically called out in the American Heart Association/American College of Cardiology hypertension guideline, which strongly recommended a team-based care approach to prevention and treatment and included pharmacists directly in that discussion.

Pharmacists have also been recognized in the ongoing Million Hearts initiative, which was originally launched in 2011 by HHS and is co-led by CDC and CMS. Its aim has always been to prevent 1 million heart attacks and strokes over a 5-year period.

In addition to keeping people healthy and optimizing care through ABCS—aspirin, BP control, cholesterol management, and smoking cessation—Million Hearts 2022 focused on specific priority populations: Black individuals, those ages 35 to 64 years (because event rates are rising), people who have had a previous heart attack or stroke, and individuals with mental illness or an SUD.

Pharmacy’s involvement on a national level

The National Hypertension Control Roundtable has a specific goal to eliminate disparities in hypertension control through dialogue, partnership, evidence, and innovations. Pharmacists are directly included in these discussions.

CDC’s Division for Heart Disease and Stroke Prevention also focuses on pharmacy-related public health applied research, which covers topic areas including states’ pharmacists’ scope of practice policy, pharmacists’ role in team-based care, pharmacists’ patient care process, and engaging pharmacists in public health programs. One current project in partnership with APhA seeks to accelerate pharmacy-based strategies to advance health equity and prevent heart disease and stroke.

Results from a recent study published October 17, 2023, in JAMA found that the Million Hearts Model, part of the broader Million Hearts initiative and which paid participating health care organizations to assess and reduce patients’ CVD risk, decreased myocardial infarction and stroke rates for Medicare fee-for-service beneficiaries ages 40 to 79 years at high or medium risk for these events.

According to the study findings, the Million Hearts Cardiovascular Disease Risk Reduction Model reduced the probability of a first-time myocardial infarction or stroke over 5 years by 0.3%, and the probability of a first-time CVD event or CVD death by 0.4% for study participants when compared with the general population.

Researchers said the results support guideline recommendations for CV risk assessment.

According to Janet Wright, MD, director of CDC’s Division for Heart Disease and Stroke Prevention, pharmacists in community pharmacy settings can provide tailored services to improve medication adherence, provide BP screenings with referrals to care when elevated, and empower patients to prioritize hypertension control. Community pharmacists can partner with local clinicians, health systems, payers, and public health departments to develop tailored programs to meet the unique needs of their patients.

“Public health is a team sport,” said Wright. “Pharmacists can and should play a crucial role in patient care. When included on health care teams, pharmacists support their patients with hypertension and help improve health outcomes.”

Wright said there is strong evidence for improved BP control in models in which pharmacists practicing in traditional clinical settings manage drug therapy, often through CPAs with prescribing clinicians. “Increased implementation of this model and adaptation to provide services in accessible community locations or through telehealth could support improved hypertension control rates, prevent CVD, and provide high economic value,” Wright said.  ■

Depending on the state, pharmacists have different options to manage heart health

While many pharmacists still face barriers to being involved in patient care on this level, some states have made substantial progress legislatively in expanding the scope of services pharmacists can offer. Below are some of the different approaches pharmacists can take to managing patients with CV risk and disease depending on the jurisdiction in which they practice.

CPAs

Although a CPA between a pharmacist and a physician is one of the most restrictive methods pharmacists can use to manage patients, it is one of the most common. Under a CPA, a pharmacist is technically “supervised” by a physician and can select, initiate, monitor, continue, or adjust patient medication regimens.

The most limiting forms of CPAs are patient-specific, in which the patient must have a relationship with the collaborating physician in order to receive services from the pharmacist. Conversely, CPAs can also be more population-specific and allow a pharmacist to provide specific services for broader populations.

The table illustrates the two different types of CPAs for CV services and which patients a pharmacist could treat in each scenario.

All 50 states have some form of law that allows for pharmacists to enter into CPAs with physicians. According to a 2016 article by Adams and Weaver published in Annals of Pharmacotherapy, nineteen of these states follow the patient-specific model, while the remaining states allow pharmacists and physicians to create CPAs that allow pharmacists to manage a broader population of patients.

Statewide protocols and standing orders

Statewide protocols and standing orders remove the barrier of pharmacists individually having to find physicians who are willing to sign off on a CPA.

For standing orders, state health regulatory agencies will often create an agreement in which any qualifying pharmacist in the state is able to sign onto an order to provide services.

Statewide protocols are a framework that specifies the conditions under which pharmacists are authorized to prescribe certain medications or medication categories when providing a clinical service.

States have implemented statewide protocols and standing orders to address CV risk primarily through allowing pharmacists to dispense or prescribe tobacco cessation products. The National Alliance for State Pharmacy Associations has an interactive map on their website which details the level of authority pharmacists have in each state to provide smoking cessation services. Since smoking history is such a large factor in determining atherosclerotic risk, patients’ ability to access smoking cessation products through their local pharmacist is a key approach to lessening the amount of people who use tobacco products.

Other services

In addition to the examples of remote BP monitoring and tobacco cessation explored above, there are several other types of services pharmacists can offer to improve CV outcomes for patients depending on the state of practice. Many of these can be done under a CPA:

Authorization of refills: Prescribers can authorize collaborating pharmacists to extend refills of chronic hypertension, hypercholesterolemia, or other CV medications based on the pharmacist’s assessment.

Therapeutic interchange: Prescribers can authorize collaborating pharmacists to substitute one drug for another, usually in the same class of medications, based on the pharmacist’s assessment.

Laboratory tests: While ordering laboratory tests such as lipid panels is typically within a pharmacist’s scope of practice if they have a Clinical Laboratory Improvement Amendments waiver, prescribers can authorize collaborating pharmacists to interpret and act on the results of such tests. This means the pharmacist could adjust a patient’s therapy based on the lipid levels indicated on a laboratory test. ■