Team-Based Care With a Pharmacist Linked to Better Blood Pressure Control
By Laurie Barclay, MD
Medscape Medical News
November 23, 2009 — Patients in whom hypertension is managed by a physician–pharmacist team have lower blood pressure (BP) levels and are more likely to reach goals for BP control than those treated by a physician alone, according to the results of a prospective, cluster randomized controlled clinical trial reported in the November 23 issue of the Archives of Internal Medicine.
"Studies have demonstrated that [BP] control can be improved when clinical pharmacists assist with patient management," write Barry L. Carter, PharmD, from the University of Iowa and Iowa City Veterans Administration, and colleagues. "The objective of this study was to evaluate if a physician and pharmacist collaborative model in community-based medical offices could improve BP control."
In this study, 402 patients (mean age, 58.3 years) with uncontrolled hypertension were enrolled at 6 clinics, of which 3 clinics were randomly assigned to a control group and 3 clinics were randomly assigned to an intervention group in which physicians and pharmacists underwent team-building exercises. Using national guidelines, clinical pharmacists made drug therapy recommendations to physicians in the intervention group. BP measurements and 24-hour BP monitoring were performed by research nurses.
In the control group, mean guideline adherence scores increased from 49.4 ± 19.3 at baseline to 53.4 ± 18.1 at 6 months (8.1% increase) compared with a 55.4% increase in the intervention group (from 40.4 ± 22.6 at baseline to 62.8 ± 13.5 at 6 months; P = .09 for adjusted between-group comparison).
Decrease in mean BP was 6.8/4.5 mm Hg in the control group compared with 20.7/9.7 mm Hg in the intervention group (P < .05 for between-group systolic BP comparison).
Adjusted difference in BP was ?12.0 mm Hg systolic (95% confidence interval [CI], ?24.0 to 0.0) and ?1.8 mm Hg diastolic (95% CI, ?11.9 to 8.3). Effect sizes were similar for 24-hour BP levels. In the control group, 29.9% of patients achieved BP control compared with 63.9% of patients in the intervention group (adjusted odds ratio, 3.2; 95% CI, 2.0 – 5.1; P < .001).
"A physician and pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates compared with a control group," the study authors write. "Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management."
Limitations of this study include the small number of clinics, factors in the control group that could have made it more difficult to achieve improvements in BP, a higher dropout rate than in a previous efficacy study, and a lack of generalizability beyond community-based family medicine offices. In addition, the findings are not generalizable to patients who are unaware of their hypertension.
"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 [BP] control," the authors conclude. "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."
In an accompanying editorial, Helene Levens Lipton, PhD, from the University of California–San Francisco, reviews this and 2 other studies suggesting that team-based interventions enhance quality of care and improve clinical outcomes, albeit with mixed effects on medical service use and costs.
"As the nation once again engages in discussions of health reform, issues of quality and cost containment are high on the agenda," Dr. Levens Lipton writes. "One approach to addressing these challenges is team-based delivery of health care services, including physicians and allied health professionals working collaboratively.... 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."
A grant from the National Heart, Lung, and Blood Institute supported this study. The Agency for Healthcare Research and Quality Centers for Education and Research on Therapeutics and the Veterans Health Administration supported some of the study authors. Dr. Levens Lipton has disclosed no relevant financial relationships.
