Comparing standard care with a physician and pharmacist team approach for uncontrolled hypertension

Abstract

OBJECTIVE:To assess the effect of a physician and pharmacist teamwork approach to uncontrolled hypertension in a medical resident teaching clinic, for patients who failed to meet the recommended goals of the fifth Joint National Commission on Detection, Evaluation and Treatment of High Blood Pressure. HYPOTHESIS:Physician and pharmacist teamwork can improve the rate of meeting national blood pressure goals in patients with previously uncontrolled hypertension. DESIGN:A single-blinded randomized controlled trial lasting 6 months. SETTING:A primary care outpatient teaching clinic. PATIENTS:A sample of 95 adult hypertensive patients who failed to meet national blood pressure goals based on three consecutive visits over a 6-month period. INTERVENTION:Patients were randomly assigned to a control arm of standard medical care or to an intervention arm in which a physician and pharmacist worked together as a team. MAIN RESULTS:At study completion, the percentage of patients achieving national goals due to intervention was more than double the percentage in the control arm (55% vs 20%, p Ͻ .001). Systolic blood pressure declined 23 mm Hg in the intervention arm versus 11 mm Hg in the control arm ( p Ͻ .01). Diastolic blood pressure declined 14 and 3 mm Hg in the intervention and control arms, respectively ( p Ͻ .001). The intervention worked equally as well in men and women and demonstrated noticeable promise in a minority of mixed-ancestry Hawaiians in whom hypertension is of special concern. CONCLUSIONS:Patients who fail to achieve national blood pressure goals under standard outpatient medical care may benefit from a program that includes a physician and pharmacist teamwork approach.KEY WORDS: blood pressure; coronary heart disease; risk factor; pharmacist; ambulatory care. J GEN INTERN MED 1998;13:740-745. G uidelines from the fifth report of the Joint NationalCommittee on Detection, Evaluation and Treatment of High Blood Pressure (JNC-V) recommend prescribing pharmacologic intervention for the treatment of patients with hypertension when 3 months of lifestyle modification fails to lower systolic or diastolic blood pressure below 140 or 90 mm Hg, respectively. 1 Published recommendations also provide for physician discretion to withhold drug therapy from patients with diastolic blood pressure less than 95 mm Hg or systolic blood pressure less than 150 mm Hg in the absence of target organ damage and other cardiovascular risk factors.According to the JNC-V criteria, up to 50 million Americans are estimated to be hypertensive. Among those being medically treated for hypertension, it is further estimated that 71% fail to achieve JNC-V goals. 1,2 A third (36%) are thought to have blood pressures that exceed even higher thresholds of 160 mm Hg for systolic blood pressure and 95 mm Hg for diastolic blood pressure. 2 Because of the widespread failure to reduce the prevalence of hypertension and to reach the goals established by the JNC-V, arguments have been made for the development and implementation of focused programs to ...

A Prospective Trial of a Clinical Pharmacy Intervention in a Primary Care Practice in a Capitated Payment System

“…S tudies have shown that pharmacist consultation programs can improve clinical outcomes by optimizing medication use in ambulatory patients. [1][2][3][4][5] Among patients in a heart failure clinic, a program of pharmacist evaluation (medication evaluation and recommendations, patient education and followup telemonitoring) resulted in a significant decrease in heart failure events and all-cause mortality. Study authors attributed this result to closer follow-up and optimizing doses of angiotensinconverting enzyme (ACE) inhibitors.…”

“…1 In 2 randomized trials of patients with hypertension, those who were treated collaboratively by physicians and pharmacists achieved better control of blood pressure than did those who were managed by the physician alone. 2,3 The physician-pharmacist team in 1 study increased medication optimization by titrating doses more effectively, switching to less expensive or more appropriate formulations of medications, and increasing appropriate laboratory monitoring. 2 Even when patients' medications were not changed, blood pressures were still improved.…”

“…2,3 The physician-pharmacist team in 1 study increased medication optimization by titrating doses more effectively, switching to less expensive or more appropriate formulations of medications, and increasing appropriate laboratory monitoring. 2 Even when patients' medications were not changed, blood pressures were still improved. The authors speculated that improved medication adherence and beneficial education about hypertension contributed to these outcomes.…”

“…The authors speculated that improved medication adherence and beneficial education about hypertension contributed to these outcomes. 2 Collaboration between physicians and pharmacists has resulted in a higher rate of patients meeting their lipid-level goals than previously achieved without collaboration in the same practice. 4 The Asheville Project demonstrated that close collaboration between community pharmacists and patients with diabetes mellitus was associated with improved blood sugar management.…”

Electronic Communications and Home Blood Pressure Monitoring (e-BP) study: Design, delivery, and evaluation framework

“…We use clinical pharmacists as the agents for changing the design of the caredelivery system, because they perform similar roles at Group Health for other chronic conditions with improved rates of statin and ACE inhibitor use in patients with heart disease and diabetes. Studies show that pharmacy care interventions have positive effects on blood pressure control and medication adherence [79][80][81][82]. Depending on local resources, however, these functions could be delegated to nurses, who might have more comfort with aspects of care unrelated to medications (e.g., lifestyle issues or clinical concerns).…”