Nov. 23, 2009 Patients whose hypertension is managed by a physician-pharmacist team have lower blood pressure levels and are more likely to reach goals for blood pressure control than those treated without this collaborative approach, according to a report in the November 23 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Previous studies suggest that patients with hypertension (high blood pressure) that remains uncontrolled often do not receive additional blood pressure medications, according to background information in the article. One strategy to improve blood pressure control is team-based care, involving the assistance of a clinical pharmacist in patient management.
Barry L. Carter, Pharm.D., of the University of Iowa and Iowa City Veterans Administration, Iowa City, and colleagues conducted a randomized, controlled clinical trial of a team-based approach in 402 patients (average age 58.3) with uncontrolled hypertension receiving care at one of six clinics. All of the clinics already employed pharmacists, but before the study the pharmacists spent more time educating pharmacy students, medical residents and staff physicians about drug therapy than they did in direct patient management.
In three clinics treating 192 patients, physicians and pharmacists underwent team-building exercises. Pharmacists also completed additional training sessions, assessed patients' blood pressure and medications at the beginning of and throughout the study, and made face-to-face treatment recommendations to physicians that were consistent with national guidelines. In the other three clinics, 210 patients were informed of their blood pressure and the blood pressure goal they should achieve, were given written information about managing blood pressure and were treated by physicians who received educational sessions on strategies to improve blood pressure control.
After six months, 29.9 percent of patients in the control group and 63.9 percent of patients in the intervention group achieved blood pressure control, defined as a blood pressure of less than 130/80 millimeters of mercury for patients with diabetes or kidney disease and 140/90 millimeters of mercury for the other patients. Average blood pressure decreased 6.8/4.5 millimeters of mercury in the control group and 20.7/9.7 millimeters of mercury in the intervention group.
The pharmacists in the intervention group made 771 recommendations; 742 (96.2 percent) were implemented by physicians. Patients in the intervention group had a greater average increase in the number of antihypertensive medications taken and more changes in their medications (including starting new medications, discontinuing current medications or increasing or decreasing dosage).
"A physician and pharmacist collaborative intervention achieved significantly better mean [average] blood pressure and overall blood pressure control rates compared with a control group," the authors conclude. "The results of this study suggest that clinics or health systems with clinical pharmacists should consider reallocation of duties to provide more direct patient management to significantly improve blood pressure control. Future studies of this model should include more clinics with greater geographic, racial/ethnic and socioeconomic diversity because these populations are likely to respond differently to the intervention."
This study was supported by a grant from the National Heart, Lung and Blood Institute.
Editorial: Team-Based Care and Medical Homes May Improve Chronic Disease Management
"As the nation once again engages in discussions of health reform, issues of quality and cost containment are high on the agenda," writes Helene Levens Lipton, Ph.D., of the University of California, San Francisco, in an accompanying editorial. "One approach to addressing these challenges is team-based delivery of health care services, including physicians and allied health professionals working collaboratively."
In addition to Carter et al's report on collaboration with pharmacists, two other reports in this issue investigate allied health providers' impact on patient care. A randomized clinical trial conducted by Jun Ma, M.D., Ph.D., of the Palo Alto Medical Foundation Research Institute, Calif., and colleagues assessed a county health care system program in which nurses and dieticians helped manage cases to reduce cardiovascular risk. In addition, Paul C. Walker, Pharm.D., of the University of Michigan, Ann Arbor, and colleagues evaluated the addition of a pharmacist to the team caring for patients discharged from general medical services of an academic medical center.
"The results of the three articles in this issue of the Archives, in the context of available literature, make the case that team-based interventions enhance quality of care and improve clinical outcomes, with mixed effects on medical service use and costs," Dr. Lipton writes. "The medical home -- a model of comprehensive health care delivery and payment reform that emphasizes the central role of primary care -- offers opportunities to implement team-based care and systematically and rigorously evaluate its effects on quality and costs."
"The baby boomers -- beneficiaries of medical and public health advances that have led to increased life expectancy, and concomitantly, chronic medical conditions -- will be placing increased demands on our health delivery system," Dr. Lipton concludes. "Among the changes that are needed to improve the quality and cost-effectiveness of their care, and in fact, to keep them in their own homes longer, the medical home is a promising innovation that can fuel advancements in team-based chronic disease management."
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- Barry L. Carter; Gail Ardery; Jeffrey D. Dawson; Paul A. James; George R. Bergus; William R. Doucette; Elizabeth A. Chrischilles; Carrie L. Franciscus; Yinghui Xu. Physician and Pharmacist Collaboration to Improve Blood Pressure Control. Arch Intern Med, 2009; 169 (21): 1996-2002 [link]
- Helene Levens Lipton. Home Is Where the Health Is: Advancing Team-Based Care in Chronic Disease Management. Arch Intern Med, 2009; 169 (21): 1945-1948 [link]
- Jun Ma; Kathy Berra; William L. Haskell; Linda Klieman; Shauna Hyde; Mark W. Smith; Lan Xiao; Randall S. Stafford. Case Management to Reduce Risk of Cardiovascular Disease in a County Health Care System. Arch Intern Med, 2009; 169 (21): 1988-1995 [link]
- Paul C. Walker; Steven J. Bernstein; Jasmine N. Tucker Jones; John Piersma; Hae-Won Kim; Randolph E. Regal; Latoya Kuhn; Scott A. Flanders. Impact of a Pharmacist-Facilitated Hospital Discharge Program: A Quasi-Experimental Study. Arch Intern Med, 2009; 169 (21): 2003-2010 [link]
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