Team-Based Care with Pharmacists to Improve Blood Pressure: a Review of Recent Literature.

PURPOSE OF REVIEW: We review studies published since 2014 that examined team-based care strategies and involved pharmacists to improve blood pressure (BP). We then discuss opportunities and challenges to sustainment of team-based care models in primary care clinics. RECENT FINDINGS: Multiple studies presented in this review have demonstrated that team-based care including pharmacists can improve BP management. Studies highlighted the cost-effectiveness of a team-based pharmacy intervention for BP control in primary care clinics. Little information was found on factors influencing sustainability of team-based care interventions to improve BP control. Future work is needed to determine the best populations to target with team-based BP programs and how to implement team-based approaches utilizing pharmacists in diverse clinical settings. Future studies need to not only identify unmet clinical needs but also address reimbursement issues and stakeholder engagement that may impact sustainment of team-based care interventions.

Proceedings From a National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention Workshop to Control Hypertension.

Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as <140/90 mm Hg, improved from 31.8% in 1999-2000 to 48.5% in 2007-2008, it remained stable through 2013-2014 and declined to 43.7% in 2017-2018. To address the rapid decline in hypertension control, the National Heart, Lung, and Blood Institute and the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention convened a virtual workshop with multidisciplinary national experts. Also, the group sought to identify opportunities to reverse the adverse trend and further improve hypertension control. The workshop immediately preceded the Surgeon General's Call to Action to Control Hypertension, which recognized a stagnation in progress with hypertension control. The presentations and discussions included potential reasons for the decline and challenges in hypertension control, possible "big ideas," and multisector approaches that could reverse the current trend while addressing knowledge gaps and research priorities. The broad set of "big ideas" was comprised of various activities that may improve hypertension control, including: interventions to engage patients, promotion of self-measured BP monitoring with clinical support, supporting team-based care, implementing telehealth, enhancing community-clinical linkages, advancing precision population health, developing tailored public health messaging, simplifying hypertension treatment, using process and outcomes quality metrics to foster accountability and efficiency, improving access to high-quality health care, addressing social determinants of health, supporting cardiovascular public health and research, and lowering financial barriers to hypertension control.

A cluster randomized trial to evaluate a centralized remote clinical pharmacy service in large, health system primary care clinics.

Background: We developed a remote cardiovascular risk service (CVRS) managed by clinical pharmacists to support primary care teams. The purpose of this study was to examine whether the CVRS could improve guideline adherence in primary care clinics with diverse geographic and patient characteristics. Methods: This study was a cluster-randomized trial initiated in 20 primary care clinics across the US. Clinics were stratified as high or low minority and then randomized to receive the intervention or maintain usual care for 12 months. The primary outcome was adherence to relevant The Guideline Advantage (TGA) criteria met. TGA is a compilation of criteria from practice guidelines intended to improve the quality of primary care. Post-hoc outcomes included changes in individual TGA measures. Results: A total of 401 study subjects were included in the analysis. Mean TGA scores remained the same in the intervention group (n=193, 0.72) and slightly decreased in the usual care group (n=208, 0.67 to 0.66) over the 12-month study period. There was no significant difference between the mean TGA scores in intervention and usual care groups for the overall population at 12 months (0.72 versus 0.66 respectively, p=0.10). For under-represented minority subjects, there was no significant difference between TGA scores at 12 months (n=186; 0.70 versus 0.67, respectively, p=0.50). In a post-hoc analysis of subjects uncontrolled at baseline, there was a significant improvement in systolic BP at 12 months in the intervention group versus usual care (model-based difference of -8.03mmHg, p=0.03). Conclusions: Improvements in individual TGA measures were limited, in part, due to higher than expected baseline TGA scores. Future studies of this model should focus on patients with uncontrolled conditions at high risk for cardiovascular events. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02215408; https://clinicaltrials.gov/ct2/show/NCT02215408?id=NCT02215408.

What does a pharmacist do? A time and motion study.

BACKGROUND: Pharmacists work in many different settings and have various responsibilities. However, pharmacists are expensive and need to be used efficiently. Previous studies have shown that prescription preparation, clinician interaction, and medical record evaluation take a large part of a pharmacist's day. Additionally, it is also estimated that almost half of their time is considered "non-value added," or that their tasks could be performed by a non-pharmacist. OBJECTIVE: To observe pharmacists in multiple practice settings and record their activities to gauge inefficiencies. METHODS: Time and motion methods were used to observe how pharmacists in retail, clinical, hospital, ambulatory, and academic settings perform daily tasks. Data was collected every 5 min for a total of 18 h from each setting, and sorted into 20 general categories of pharmacists' tasks. RESULTS: Pharmacists spend more time verifying prescriptions than any other activity, accounting for 31% of their time. Other common activities were patient education, charting, counseling, and chart review. CONCLUSION: Although most of pharmacists' daily activities add value to the healthcare team, there are ways to use their time more efficiently. Along with delegating tasks to other pharmacy personnel, new initiatives designed to help pharmacists increase time spent on value-added tasks are recommended.

Cost-Effectiveness of a Physician-Pharmacist Collaboration Intervention to Improve Blood Pressure Control.

Previous studies have demonstrated the cost-effectiveness of physician-pharmacist collaborations to improve hypertension control. However, most studies have limited generalizability, lacking minority and low-income populations. The Collaboration Among Pharmacist and Physicians to Improve Blood Pressure Now (CAPTION) trial randomized 625 patients from 32 medical offices in 15 states. Each office had an existing clinical pharmacist on staff. Pharmacists in intervention offices communicated with patients and made recommendations to physicians about changes in therapy. Demographic information, blood pressure (BP), medications, and physician visits were recorded. In addition, pharmacists tracked time spent with each patient. Costs were assigned to medications and pharmacist and physician time. Cost-effectiveness ratios were calculated based on changes in BP measurements and hypertension control rates. Thirty-eight percent of patients were black, 14% were Hispanic, and 49% had annual income <$25 000. At 9 months, average systolic BP was 6.1 mm Hg lower (±3.5), diastolic was 2.9 mm Hg lower (±1.9), and the percentage of patients with controlled hypertension was 43% in the intervention group and 34% in the control group. Total costs for the intervention group were $1462.87 (±132.51) and $1259.94 (±183.30) for the control group, a difference of $202.93. The cost to lower BP by 1 mm Hg was $33.27 for systolic BP and $69.98 for diastolic BP. The cost to increase the rate of hypertension control by 1 percentage point in the study population was $22.55. Our results highlight the cost-effectiveness of a clinical pharmacy intervention for hypertension control in primary care settings.