Pharmacists on health care teams, in diverse physician practices, lower blood pressure

Intervention in University of Iowa study could be scaled up

Clinical pharmacists on the health care team in physicians’ offices can have a major role in chronic therapy management for patients with a wide array of medical issues.

That was demonstrated by a new study from researchers at the University of Iowa. Clinical pharmacists working in collaboration with primary care physicians in these settings can improve blood pressure control, according to the cluster-randomized trial. In addition, the study found that for most patients who don’t have their disease under control, intensifying medication regimens worked best.

“The pharmacist needs to be at the front end of those discussions to design and modify those regimens and then monitor them—that’s what we mean by comprehensive medication therapy management,” Barry Carter, PharmD, FCCP, FAHA, FASH, BCPS, told Pharmacy Today. Carter is Patrick E. Keefe Professor in Pharmacy at the University of Iowa College of Pharmacy and a professor in the Department of Family Medicine at the College of Medicine.

Identifying issues early

The study appeared in the May 2015 issue of Circulation: Cardiovascular Quality and Outcomes, published by the American Heart Association. The research team, led by Carter, evaluated 625 patients from various racial backgrounds with uncontrolled hypertension from 32 medical offices in the United States. Fifty percent of the patients also had diabetes or chronic kidney disease, and 54% came from racial or ethnic minority groups.

All of the physician offices had a clinical pharmacist on the care team. The typical office was a family medicine training office with about 30–40 physicians on staff, as well as nurse practitioners, physician assistants, and nutritionists.

Initially, clinical pharmacists saw patients for a baseline visit and then for additional visits for an average total of five visits over a 9-month period. During the visits, clinical pharmacists measured the patients’ blood pressure control and evaluated the intensity of care they were receiving and how well they were adhering to their medication regimen.

Carter said a key aspect in making the intervention work was having the clinical pharmacist spend a fair amount of time with the patient during the baseline visit.

“Regardless of the issue, the thing that works best is if the pharmacist does something right then and there at that baseline visit,” said Carter. “Mostly we have found that means increasing medications—while some people have adherence issues, the vast majority of problems arise when their [the patient’s] medication regimen is not being intensified.”

Overall, results of the study found that patients who saw a clinical pharmacist had a systolic blood pressure drop of 6.1 mm Hg after 9 months compared with those who did not.

Tyler Gums, PharmD, a family medicine research fellow at the University of Iowa who was working with Carter, looked deeper into the cause of the drop in blood pressure. He examined physician acceptance and found that physicians welcomed pharmacists as part of the care team, with acceptance rates over 97%, according to Gums. They also looked at medication use and adherence. They found that patients had more medication changes when they received care from a pharmacist, but identifying exact adherence issues was tougher to determine.

Gums found that patients were not more adherent to blood pressure medication when a pharmacist was part of the care team, and hopes to investigate this finding more.

“We believe if pharmacists can learn and implement better nonadherent identification and intervention techniques, we can make the physician–pharmacist collaboration model stronger than ever,” said Gums.

Scaling up

The other important takeaway from the study, according to Carter, is that the intervention could be scaled up in diverse practices and with a diverse population. In addition, with many private practices now aligning with larger health systems—whether through accountable care organizations or otherwise—the results highlight an opportunity for health systems to recognize the role of pharmacists in these new models of care.

“My hope is that we are beginning to see the light at the end of the tunnel—that these new payment structures and the desire for quality outcomes are going to be the reason these [interventions with pharmacists] will get scaled up much more quickly than they have in the past,” said Carter.