Physician and pharmacist collaboration to improve blood pressure control

The Long-Term Blood Pressure Trends Following a Remote Hypertension Intervention: A Secondary Analysis of the Digital Care Transformation - Remotely Delivered Hypertension Management Program

BACKGROUND

Hypertension is a major cardiovascular risk factor, yet traditional care often results in suboptimal blood pressure (BP) control at the population level. We implemented a remote hypertension management program that monitored home BP and titrated medications per algorithm. This study assessed the program's long-term effects by examining participants' office BP up to 42 months post-enrollment.

METHODS

Participants of the remote hypertension program were categorized into 4 groups: (1) enrolled-maintenance (achieved goal home BP of ≤130/80 mm Hg), (2) enrolled-early exit (left before achieving goal BP), (3) education-only (lifestyle modifications and medications compliance), and (4) white coat hypertension group (high office BP but normal home BP). Office BP readings of participants were collected up to 42 months post-enrollment. A linear mixed-effects regression model estimated mean BP levels and studied factors associated with above-goal systolic BP in the maintenance group.

RESULTS

Office BP readings from 3601 participants (mean age, 61±11 years; 57% female; 60% white; 52% atherosclerotic cardiovascular disease) were extracted from electronic health records and analyzed. All groups sustained office BP below their qualifying values (P<0.001) over 42 months. In the maintenance group, 89.7% of participants maintained systolic BP at goal, compared with 63.5% in the early exit group, 69.4% in the education-only group, and 90.7% in the white coat hypertension group. Age >50 years was associated with above-goal systolic BP in the maintenance group.

CONCLUSIONS

Participants who achieved BP control through the remote hypertension program maintained goal systolic BP in 90% of cases up to 42 months post-enrollment. These findings highlight the long-term benefits of remote, intensive management programs for effective hypertension control.

Pharmacists delivering hypertension care services: a systematic review and meta-analysis of randomized controlled trials

Background

Community-based models of care with the involvement of pharmacists and other nonphysician healthcare professionals can help improve blood pressure (BP) control. We aimed to synthesize the evidence of effectiveness of pharmacist interventions on BP among patients with hypertension.

Methods

We performed systematic searches to identify randomized controlled trials (RCTs) assessing the effect of pharmacist interventions on BP among outpatients (latest search, March 2024). The effect on systolic and diastolic BP change or BP control were pooled using random effects model. Subgroup analysis for the types of pharmacist interventions and healthcare settings were performed. The risk of bias was assessed using the Cochrane Risk of Bias Tool 2. The protocol was registered in PROSPERO (CRD42021279751) and published in an open-access peer-reviewed journal.

Results

Out of 2,330 study records identified in 7 electronic databases, a total of 95 RCTs, with 31,168 participants (control 16,157, intervention 15,011), were included. The intervention was led by the pharmacist in 75% of the studies and in collaboration with other healthcare providers in 25%. Pharmacist interventions included patient education in 88%, feedback to healthcare providers in 49%, and patient reminders in 24% of the studies. Systolic and diastolic BP were reduced after pharmacist intervention by -5.3 mmHg (95% CI: -6.3 to -4.4; I 2 = 86%) and -2.3 mmHg (95% CI: -2.9 to -1.8; I 2 = 75%), respectively. The reduction of systolic BP tended to be larger if the intervention was collaborative, conducted in outpatient clinics, based on healthcare provider education, or through healthcare provider feedback. Analyses restricted to relatively large or high-quality studies yielded similar estimates, with lower between-studies heterogeneity.

Conclusion

Pharmacist care for patients with hypertension consistently improves BP across various settings and interventions. Pharmacist care is one key element of the solution to the global burden of hypertension and cardiovascular diseases.

PROSPERO registration number

CRD42021279751.

Closing the Gap: Digital Innovations to Address Hypertension Disparities

PURPOSE OF REVIEW

Significant inequities persist in hypertension detection and control, with minoritized populations disproportionately experiencing organ damage and premature death due to uncontrolled hypertension. Remote blood pressure monitoring combined with telehealth visits (RBPM) is proving to be an effective strategy for controlling hypertension. Yet there are challenges related to technology adoption, patient engagement and social determinants of health (SDoH), contributing to disparities in patient outcomes. This review summarizes the evidence to date for RBPM, focusing on the potential to advance health equity in blood pressure control and the existing levers for largescale implementation.

RECENT FINDINGS

Several studies demonstrate the promise of RBPM programs to address health disparities through: (1) the use of cellular-enabled blood pressure machines that do not require internet access or smart devices to connect readings into the medical record; (2) emphasis on home blood pressure monitoring to illuminate the daily factors that influence blood pressure control, thereby increasing patient empowerment; (3) adoption of standardized algorithms for hypertension management; and (4) integration of services to address SDoH. Multidisciplinary, non-physician care teams that include nurses, pharmacists, and community health workers are integral to this model. However, most studies have not embraced all aspects of RBPM, and implementation is challenging as current payment models do not support the digital components of RBPM or a diverse workforce of hypertension providers.

CONCLUSION

To address hypertension disparities, RBPM programs need to integrate digital technology that is accessible to all users as well as multidisciplinary care teams that attend to the medical and social needs of populations experiencing health inequities.

Role of Health Care Professionals in the Success of Blood Pressure Control Interventions in Patients With Hypertension: A Meta-Analysis

BACKGROUND

Globally, only 13.8% of patients with hypertension have their blood pressure (BP) controlled. Trials testing interventions to overcome barriers to BP control have produced mixed results. Type of health care professional delivering the intervention may play an important role in intervention success. The goal of this meta-analysis is to determine which health care professionals are most effective at delivering BP reduction interventions.

METHODS

We searched Medline and Embase (until December 2023) for randomized controlled trials of interventions targeting barriers to hypertension control reporting who led intervention delivery. One hundred articles worldwide with 116 comparisons and 90 474 participants with hypertension were included. Trials were grouped by health care professional, and the effects of the intervention on systolic and diastolic BP were combined using random effects models and generalized estimating equations.

RESULTS

Pharmacist-led interventions , community health worker-led interventions, and health educator-led interventions resulted in the greatest systolic BP reductions of -7.3 (95% CI, -9.1 to -5.6), -7.1 (95% CI, -10.8 to -3.4), and -5.2 (95% CI, -7.8 to -2.6) mm Hg, respectively. Interventions led by multiple health care professionals, nurses, and physicians also resulted in significant systolic BP reductions of -4.2 (95% CI, -6.1 to -2.4), -3.0 (95% CI, -4.2 to -1.9), and -2.4 (95% CI, -3.4 to -1.5) mm Hg, respectively. Similarly, the greatest diastolic BP reductions were -3.9 (95% CI, -5.2 to -2.5) mm Hg for pharmacist-led and -3.7 (95% CI, -6.6 to -0.8) mm Hg for community health worker-led interventions. In pairwise comparisons, pharmacist were significantly more effective than multiple health care professionals, nurses, and physicians at delivering interventions.

CONCLUSIONS

Pharmacists and community health workers are most effective at leading BP intervention implementation and should be prioritized in future hypertension control efforts.

Involving community pharmacists in interprofessional collaboration in primary care: a systematic review

BACKGROUND

The World Health Organization supports interprofessional collaboration in primary care. On over the past 20 years, community pharmacists had been taking a growing number of new responsibilities and they are recognized as a core member of collaborative care teams as patient-centered care providers. This systematic review aimed to describe interprofessional collaboration in primary care involving a pharmacist, and its effect on patient related outcomes.

METHODS

A systematic review of randomized controlled trials cited in the MEDLINE, EMBASE, PsycInfo and CINAHL in English and French was conducted from inception to November 2022. Studies were included if they described an intervention piloted by a primary care provider and included a pharmacist and if they evaluated the effects of intervention on a disease or on patient related outcomes. The search generated 3494 articles. After duplicates were removed and titles and abstracts screened for inclusion, 344 articles remained.

RESULTS

Overall, 19 studies were included in the review and assessed for quality. We found 14 studies describing an exclusive collaboration between physician and pharmacist with for all studies a three-step model of pharmacist intervention: a medication review, an interview with the patient, and recommendations made to physician. Major topics in the articles eligible for inclusion included cardiovascular diseases with blood pressure, diabetes, dyslipidemia, and risk of cardiovascular diseases. Positive effects concerned principally blood pressure.

CONCLUSIONS

Collaboration involving pharmacists is mainly described in relation to cardiovascular diseases, for which patient-centered indicators are most often positive. It underscores the need for further controlled studies on pharmacist-involved interprofessional collaboration across various medical conditions to improve consensus on core outcomes measures.

Reimagining Medication Adherence: A Novel Holistic Model for Hypertension Therapy

Purpose

Patients' adherence to the prescribed therapy is influenced by several personal and social factors. However, existing studies have mostly focused on individual aspects. We took a holistic approach to develop a higher-level impact factor model.

Patients and Methods

In this independent, non-interventional, cross-sectional and anonymous study design the pharmacist recruited patients who entered the pharmacy and handed in a prescription for a blood pressure medication. The patients received a paper questionnaire with a stamped return envelope to volunteer participation. A total of 476 patients in Germany who reported having at least high normal blood pressure according to the Global Hypertension Practice Guidelines were surveyed. In this study, each patient received an average of 2.49 antihypertensive prescriptions and 7.9% of all patients received a fixed-dose combination. Partial least squares structural equation modeling was performed for model analytics since it enables robust analysis of complex relationships.

Results

Emotional attitude, behavioral control, and therapy satisfaction directly explained 65% of therapy adherence. The predictive power of the out-of-sample model for the Q2-statistic was significant. The patient's overall therapy satisfaction determined medication adherence. The medication scheme's complexity also influenced the adherence levels. Therapy satisfaction was significantly shaped by the complexity of the medication scheme, behavioral control, and emotional attitude. The results demonstrated the superior performance of fixed-dose combinations against combinations of mono-agents according to the adherence level. Additionally, patient-physician and patient-pharmacist relationships influenced behavioral control of medication therapy execution. According to the A14-scale to measure the level of adherence, 49.6% of patients were classified as adherent and the remainder as non-adherent.

Conclusion

The results enable healthcare stakeholders to target attractive variables for intervention to achieve maximum effectiveness. Moreover, the proven predictive power of the model framework enables clinicians to make predictions about the adherence levels of their hypertensive patients.

Remote follow-up by pharmacists for blood pressure control in patients with hypertension: a systematic review and a meta-analysis of randomized controlled trials

Hypertension is a major cause of cardiovascular diseases. Several recent studies reported that pharmacists' remote follow-up reduced hypertension patients' blood pressure (BP). This meta-analysis aims to verify whether remote follow-up by pharmacists improves BP levels and reveal the factors that make the intervention effective. The search, conducted using PubMed/Medline, Embase, and Cochrane Library from June to July 2023, targeted articles published between October 1982 and June 2023, using terms including "pharmacist", "hypertension", and "randomized controlled trial (RCT)". The inclusion criteria were: (a) RCTs involving hypertension patients with or without comorbidities, (b) pharmacists using remote communication tools to conduct follow-up encounter during the intervention period, (c) reporting systolic blood pressure (SBP) at baseline and during intervention. SBP was the primary outcome for the meta-analysis. Thirteen studies (3969 participants) were included in this meta-analysis. The mean difference of SBP between intervention group and control group was - 7.35 mmHg (P < 0.0001). Subgroup analyses showed the greater reduction of SBP in the "regularly scheduled follow-up cohort" (- 8.89 mmHg) compared with the "as needed follow-up cohort" (- 3.23 mmHg, P < 0.0001). The results revealed that remote follow-up by pharmacists reduced SBP levels in hypertension patients and scheduled remote follow-up may contribute to the effectiveness.

Prescribers' approval rate of pharmacist-initiated interventions to optimise patients' clinical status of hypertension in the ambulatory care setting

This perspective, pre- and post-intervention study with a one-year follow-up primarily aimed to ascertain prescribers' approval rate of pharmacists' interventions and clinical status of hypertension following comprehensive medication management (CMM) intervention in the ambulatory care clinic. Between January 2018 and January 2022 overall 100 patients with hypertension and other comorbidities were referred to the CMM services at the Health Centre Zagreb - Centar (HCZC). Out of 275 interventions directed to prescribers, 73.1 % of interventions were approved, 12.4 % were rejected and 14.5 % were not reviewed. The percentage of patients with a blood pressure goal increased from 45 % at the initial consultation to 82.5 % at the patients' latest encounter (p < 0.001). The average number of drug therapy problems (DTPs) per patient totaled 3.53 ± 1.80, where 98 % of patients had one or more DTPs, 48 % had 4 or more DTPs, whereas 26 % had 5 or more DTPs. Sub-therapeutic dosage (32.6 %) and the need for additional drug therapy (30.9 %) were the two most commonly identified DTPs. These results reinforce the need to integrate pharmacy-led services in the primary care setting with the aim of improving patients' health outcomes.

Interprofessional collaboration in primary care: what effect on patient health? A systematic literature review

BACKGROUND

In a period of change in the organization of primary care, Interprofessional Collaboration (IPC) is presented as one of the solutions to health issues. Although the number of inter-professional interventions grounded in primary care increases in all developed countries, evidence on the effects of these collaborations on patient-centred outcomes is patchy. The objective of our study was to assess the effects of IPC grounded in the primary care setting on patient-centred outcomes.

METHODS

We conducted a systematic literature review using the PubMed, Embase, PsycINFO and CINAHL databases from 01/01/1995 to 01/03/2021, according to the PRISMA guidelines. Studies reporting the effects of IPC in primary care on patient health outcomes were included. The quality of the studies was assessed using the revised Downs and Black checklist.

RESULTS

Sixty-five articles concerning 61 interventions were analysed. A total of 43 studies were prospective and randomized. Studies were classified into 3 main categories as follows: 1) studies with patients at cardiovascular risk (28 studies)-including diabetes (18 studies) and arterial hypertension (5 studies); 2) studies including elderly and/or polypathological patients (18 studies); and 3) patients with symptoms of mental or physical disorders (15 studies). The number of included patients varied greatly (from 50 to 312,377). The proportion of studies that reported a positive effect of IPC on patient-centred outcomes was as follows: 23 out of the 28 studies including patients at cardiovascular risk, 8 out of the 18 studies of elderly or polypathological patients, and 11 out of the 12 studies of patients with mental or physical disorders.

CONCLUSIONS

Evidence suggests that IPC is effective in the management of patients at cardiovascular risk. In elderly or polypathological patients and in patients with mental or physical disorders, the number of studies remains very limited, and the results are heterogeneous. Researchers should be encouraged to perform studies based on comparative designs: it would increase evidence on the positive effect and benefits of IPC on patient variables.

Effect of Pharmaceutical Intervention in Pharmacologically Treated Hypertensive Patients-A Cluster-Randomized Clinical Trial: AFPRES-CLM Study

BACKGROUND

Evaluate the effect of a community pharmaceutical intervention on the control of blood pressure in hypertensive patients treated pharmacologically.

METHODS

A cluster-randomized clinical trial of 6 months was carried out. It was conducted in the Autonomous Community of Castilla-La Mancha (Spain). Sixty-three community pharmacies and 347 patients completed the study. Intervention patients received the community pharmaceutical intervention based on a protocol that addresses the individual needs of each patient related to the control of their blood pressure, which included Health Education, Pharmacotherapy Follow-up and 24 h Ambulatory Blood Pressure Measurement. Control patients received usual care in the community pharmacy.

RESULTS

The pharmaceutical intervention resulted in better control of blood pressure (85.8% vs. 66.3% p < 0.001), lower use of emergencies (p = 0.002) and improvement trends in the physical components of quality of life, measured by SF-36 questionnaire, after 6 months of pharmaceutical intervention. No significant changes were observed for any of these variables in the control group. There were also detected 354 negative medication-related outcomes that were satisfactorily resolved in a 74.9% of the cases and 330 healthcare education interventions and 29 Ambulatory Blood Pressure Monitorings were performed in order to increase adherence to pharmacological treatment and minimize Negative Outcomes associated with Medication and prevent medication-related problems.

CONCLUSIONS

Community pharmaceutical intervention can increase hypertensive patients with controlled blood pressure, after 6 months, compared with usual care.

General practitioners' perceptions of the roles of community pharmacists and their willingness to collaborate with pharmacists in primary care

BACKGROUND

Community pharmacists (CPs) have the capacity to contribute to patient care given their expertise in medication and accessibility to residents in the community. However, multidisciplinary patient care programmes where CPs collaborate with general practitioners (GPs) in patient care is rare in Singapore despite increasing healthcare demand.

OBJECTIVES

This study explores GPs' perceptions of CPs' current roles and GPs' ideas for and attitudes towards interprofessional collaboration.

METHODS

Semi-structured qualitative interviews were conducted with 20 private GPs from August to December 2020 via an online video-chat platform. GPs were recruited from the Primacy Care Research Network (pcRn), primary care networks, and using snowballing strategies. All interviews were recorded, transcribed and coded thematically.

RESULTS

Current working relationships between GPs and CPs appeared amicable but limited. GPs appreciate the existing roles of CPs: dispensing drugs not stocked in their practices and clarifying prescription details. Still, GPs appeared to rarely consider collaborative working. GPs acknowledged that CPs could enhance patient care with initiatives including medication reconciliation and advising on using medical devices. It was suggested that CPs could coordinate the purchase of drugs for primary care networks to improve GPs' inventory management, but less enthusiasm was expressed for clinical collaborations with CPs. Major concerns about GP-CP clinical collaborations included direct competition with GPs' own business interests, perceived low acceptability of pharmacy-led services by patients (citing extra time and cost), threat to continuity of care and the absence of a shared patient electronic health record system. Current funding mechanisms do not enable reimbursement of clinical services provided by CPs. Adoption of telemedicine technologies and governmental financial support were identified as possible enablers of GP-CP collaboration.

CONCLUSIONS

GPs saw potential in CPs' increased involvement in patient care, but perceived multiple barriers. Strategies focusing on overcoming these barriers could enable GP-CP collaboration to enhance patient care.

Real-World Effectiveness in Hypertension and Hyperlipidemia Collaborative Management between Pharmacies and Primary Care in Portugal: A Multicenter Pragmatic Controlled Trial (USFarmácia®)

There is evidence of the efficacy of collaborative health interventions with pharmacies and primary care providers but little of its real-world effectiveness. We aimed to assess the effectiveness and discuss the design and challenges of hypertension and hyperlipidemia management between pharmacies and primary care providers using real-world data exchange between providers and experimental bundled payment. This was a pragmatic, quasi-experimental controlled trial. We collected patient-level data from primary care prescription claims and Electronic Medical Record databases, a pharmacy claims database, and patient telephone surveys at several time points. The primary outcomes were changes in blood pressure and total cholesterol. We used matched controls with difference-in-differences estimators in a Generalized Linear Model (GLM) and controlled interrupted time series (CITS). We collected additional data for economic and qualitative studies. A total of 6 Primary Care Units, 20 pharmacies, and 203 patients entered the study. We were not able to observe significant differences in the effect of intervention vs. control. We experienced challenges that required creative strategies. This real-world trial was not able to show effectiveness, likely due to limitations in the primary care technology which affected the sample size. It offers, however, valuable lessons on methods, strategies, and data sources, paving the way for more real-world effectiveness trials to advance value-based healthcare.

Effectiveness and Cost-Effectiveness of Team-Based Care for Hypertension: A Meta-Analysis and Simulation Study

BACKGROUND

Team-based care (TBC), a team of ≥2 healthcare professionals working collaboratively toward a shared clinical goal, is a recommended strategy to manage blood pressure (BP). However, the most effective and cost-effective TBC strategy is unknown.

METHODS

A meta-analysis of clinical trials in US adults (aged ≥20 years) with uncontrolled hypertension (≥140/90 mm Hg) was performed to estimate the systolic BP reduction for TBC strategies versus usual care at 12 months. TBC strategies were stratified by the inclusion of a nonphysician team member who could titrate antihypertensive medications. The validated BP Control Model-Cardiovascular Disease Policy Model was used to project the expected BP reductions out to 10 years and simulate cardiovascular disease events, direct healthcare costs, quality-adjusted life years, and cost-effectiveness of TBC with physician and nonphysician titration.

RESULTS

Among 19 studies comprising 5993 participants, the 12-month systolic BP change versus usual care was -5.0 (95% CI, -7.9 to -2.2) mm Hg for TBC with physician titration and -10.5 (-16.2 to -4.8) mm Hg for TBC with nonphysician titration. Relative to usual care at 10 years, TBC with nonphysician titration was estimated to cost $95 (95% uncertainty interval, -$563 to $664) more per patient and gain 0.022 (0.003-0.042) quality-adjusted life years, costing $4400/quality-adjusted life year gained. TBC with physician titration was estimated to cost more and gain fewer quality-adjusted life years than TBC with nonphysician titration.

CONCLUSIONS

TBC with nonphysician titration yields superior hypertension outcomes compared with other strategies and is a cost-effective way to reduce hypertension-related morbidity and mortality in the United States.

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

A bibliometric analysis of global trends in the research field of pharmaceutical care over the past 20 years

Pharmaceutical care is essential in building up the basics of public health and clinical care. A comprehensive understanding of global status in the field of pharmaceutical care is necessary for directing its research frontiers and future trends. Therefore, this study aims to make a bibliometric analysis to track the development of pharmaceutical care research worldwide during the past two decades. The publications regarding pharmaceutical care were culled from the Web of Science Core Collection (WoSCC). Countries, institutions, authors, journals, references, and keywords in this field were visually analyzed by using VOSviewer (version 1.6.17) and CiteSpace (Version 5.8.R3). As a result, 3,597 publications (3,177 articles and 420 reviews) were obtained. The annual yields grew more than three times in the past two decades, from 54 records in 2002 to 379 papers in 2021. The United States played the leading role in this research from multiple aspects, including publication (n = 1,208), citations (n = 28,759), funding agencies, and collaboration worldwide. The University of Sydney in Australia was the most contributed institution with the greatest number of publications (n = 112) in pharmaceutical care research. Hersberger KE from the University of Basel was the most productive author (n = 40). Chen TF from the University of Sydney was the author who owed the highest H-index of 19 and most citations (n = 1,501). They both significantly impacted this field. American Journal of Health System Pharmacy produced the most publications, while Pharmacotherapy had the highest IF (IF2020 = 4.705) in this field. Clusters networks of co-cited references and keywords suggested that clinical pharmacy is an essential theme in pharmaceutical care. Terms of medication safety and critical care recognized by burst analysis of keywords also hint at the recent attention on clinical pharmacy. The present bibliometrics analysis may provide a comprehensive overview and valuable reference for future researchers and practitioners in the research field of pharmaceutical care.

Addressing Women’s Needs with Human Immunodeficiency Virus (HIV) and Enhancing the Visibility of Pharmacists in the Public Health Arena

Human Immunodeficiency Virus (HIV) continues to have a staggering effect on women’s lives in the United States (U.S.). Women Living With HIV (WLWH) face many challenges, such as mental health disorders, compared to their male counterparts. These diagnoses make women more disproportionally affected, and meaningful healthcare interventions must address these conditions. This review has three foci: WLWH in the U.S., their access to care and staying in care once antiretroviral treatment has been initiated, coping with mental health, and the role of the U.S. pharmacists in access to the treatment. Pharmacists are the most easily accessible healthcare profession in the U.S. For example, 93% of American customers live within 5 miles of a community pharmacy. Pharmacists are the last healthcare provider with whom the patient interacts before a medication is dispensed; thus, they are in an ideal position to intervene. Engaging pharmacists to provide care for patients with chronic disease states such as HIV has resulted in positive outcomes. Although there are global and U.S. studies that emphasize the role of pharmacists in directing care for persons living with HIV, there is a lack of studies conducted about the role of pharmacists in managing mental health. Future research must address WLWH and mental health conditions to develop targeted interventions from an interdisciplinary team perspective.

Impact of Pharmacist-Led Clinics on Health Outcomes of Patients With Diabetes at a Ministry of Health Diabetes & Endocrinology Center, Saudi Arabia: A Retrospective Study

Objectives: Saudi Arabia is one of the most diabetes-prone countries in the world. The physician‐centered model of care constitutes the standard of care around the country. The study aimed to evaluate the impact of clinical pharmacist care on diabetes management in comparison to standard physician-based care.

Materials and methods: a retrospective chart review was conducted of patients with type 2 diabetes mellitus (T2DM) seen by the clinical pharmacist at the Diabetes & Endocrinology Center, King Fahad Specialist Hospital located in Buraydah, Saudi Arabia between September 2019 to June 2020.

Results: Thirty-two diabetic patients were included. The mean age is 55.75±10.72 years with 65.6% of patients being females. Hemoglobin A1c (HbA1c) was significantly decreased within nine months compared to baseline (9.33±1.80 vs.10.30±1.66), p=0.017.

Conclusions: The multidisciplinary collaborative care involving pharmacists achieved superior diabetes outcomes for patients with diabetes. Involving pharmacists resulted in a significant HbA1c reduction within nine months. Moreover, pharmacists’ care helped optimize medication therapy and decreased the frequency of hypoglycemia.

Community-Based Rehabilitation Promotes the Functional Recovery of Patients After Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH), a severe disorder with the high death rate, high recurrence rate and high disability rate, affected the quality of human life. Community-based rehabilitation (CBR) helps disabled people at both community and family levels. However, the effect of CBR on the recovery of people after ICH remains unclear.

METHODS

Patients were treated with the CBR training program, subsequently, medication compliance test, clinical neural impairment measurements, functional comprehensive assessments, improved Barthel index score, and life qualities assessments were to performed at 3-month or 6-month intervention of CBR to evaluate the influence of CBR on the medication compliance, physical function and life quality of patients after ICH.

RESULTS

After the treatment of CBR, we observed that, the rate of medication compliance, motor function, functional comprehensive rating scale score, modified Barthel index score, and generic quality of life inventory-74 in the CBR-treated group were significantly higher than that in the control group; the neural impairment measure score in the CBR-treated group was significantly decreased in comparison to the control group.

CONCLUSION

CBR increased the medication compliance, promoted the recovery of the neurological function and improved the life qualities of ICH patients.

Effectiveness of a medication adherence management intervention in a community pharmacy setting: a cluster randomised controlled trial

BACKGROUND

Non-adherence to medications continues to be a burden worldwide, with significant negative consequences. Community pharmacist interventions seem to be effective at improving medication adherence. However, more evidence is needed regarding their impact on disease-specific outcomes. The aim was to evaluate the impact of a community pharmacist-led adherence management intervention on adherence and clinical outcomes in patients with hypertension, asthma and chronic obstructive pulmonary disease (COPD).

METHODS

A 6-month cluster randomised controlled trial was conducted in Spanish community pharmacies. Patients suffering from hypertension, asthma and COPD were recruited. Patients in the intervention group received a medication adherence management intervention and the control group received usual care. The intervention was based on theoretical frameworks for changing patient behaviour. Medication adherence, disease-specific outcomes (Asthma Control Questionnaire (ACQ) scores, Clinical COPD Questionnaire (CCQ) scores and blood pressure levels) and disease control were evaluated. A multilevel regression model was used to analyse the data.

RESULTS

Ninety-eight pharmacies and 1186 patients were recruited, with 1038 patients completing the study. Patients receiving the intervention had an OR of 5.12 (95% CI 3.20 to 8.20, p<0.05) of being adherent after the 6 months. At the end of the study, patients in the intervention group had lower diastolic blood pressure levels (mean difference (MD) -2.88, 95% CI -5.33 to -0.43, p=0.02), lower CCQ scores (MD -0.50, 95% CI -0.82 to -0.18, p<0.05) and lower ACQ scores (MD -0.28, 95% CI -0.56 to 0.00, p<0.05) when compared with the control group.

CONCLUSIONS

A community pharmacist-led medication adherence intervention was effective at improving medication adherence and clinical outcomes in patients suffering from hypertension, asthma and COPD. Future research should explore the implementation of these interventions in routine practice.

TRIAL REGISTRATION NUMBER

ACTRN12618000410257.

Internet+Continuing Nursing (ICN) Program Promotes Motor Function Rehabilitation of Patients With Ischemic Stroke

BACKGROUND AND PURPOSE

Ischemic stroke is a severe disorder with high rates of death and recurrence that causes disability in patients and for which there is currently no effective treatment. Internet-based rehabilitation helps patients with disability recover at home with the help of their household or family members in a nonclinical setting. However, the effects of the internet+continuing nursing (ICN) program on the recovery of patients after ischemic stroke remains unknown.

METHODS

In the present study, patients were treated with an ICN-based rehabilitation training program; subsequently, the Self-efficacy Scale for Chronic Disease, Questionnaire of Exercise Adherence, Motor Assessment Scale, Activities of Daily Living, and Stroke-specific Quality of Life were performed to evaluate the effects of the ICN program on patient self-confidence to persist with rehabilitation, functional exercise compliance, motor function, ability to live independently and quality of life following ischemic stroke.

RESULTS

We observed that, after the ICN intervention for 6 weeks and 3 months, the scores of Self-efficacy Scale for Chronic Disease, Questionnaire of Exercise Adherence, Motor Assessment Scale, Activities of Daily Living, and Stroke-specific Quality of Life in the ICN-treated group were significantly higher compared with those in the control group.

CONCLUSION

These results suggested that the ICN program may promote the recovery of patients after ischemic stroke.

The cost-effectiveness of pharmacist-physician collaborative care models vs usual care on time in target systolic blood pressure range in patients with hypertension: a payer perspective

BACKGROUND: Hypertension is highly prevalent in the United States, affecting nearly half of all adults (43%). Studies have shown that pharmacist-physician collaborative care models (PPCCMs) for hypertension management significantly improve blood pressure (BP) control rates and provide consistent control of BP. Time in target range (TTR) for systolic BP is a novel measure of BP control consistency that is independently associated with decreased cardiovascular risk. There is no evidence that observed improvement in TTR for systolic BP with a PPCCM is cost-effective. OBJECTIVE: To compare the cost-effectiveness of a PPCCM with usual care for the management of hypertension from the payer perspective. METHODS: We used a decision analytic model with a 3-year time horizon based on published literature and publicly available data. The population consisted of adult patients who had a previous diagnosis of high BP (defined as office-based BP ≥ 140/90 mmHg) or were receiving antihypertensive medications. Effectiveness data were drawn from 2 published studies evaluating the effect of PPCCMs (vs usual care) on TTR for systolic BP and the impact of TTR for systolic BP on 4 cardiovascular outcomes (nonfatal myocardial infarction [MI], stroke, heart failure [HF], and cardiovascular disease [CVD] death). The model incorporated direct medical costs, including both programmatic costs (ie, direct costs for provider time) and downstream health care utilization associated with acute cardiovascular events. One-way sensitivity and threshold analyses examined model robustness. RESULTS: In base-case analyses, PPCCM hypertension management was associated with lower downstream medical expenditures (difference: -$162.86) and lower total program costs (difference: -$108.00) when compared with usual care. PPCCM was associated with lower downstream medical expenditures across all parameter ranges tested in the deterministic sensitivity analysis. For every 10,000 hypertension patients managed with PPCCM vs usual care over a 3-year time horizon, approximately 27 CVD deaths, 29 strokes, 21 nonfatal MIs, and 12 incident HF diagnoses are expected to be averted. CONCLUSIONS: This is the first study to evaluate the cost-effectiveness of PPCCM compared to usual care on TTR for systolic BP in adults with hypertension. PPCCM was less costly to administer and resulted in downstream health care savings and fewer acute cardiovascular events relative to usual care. Although further research is needed to evaluate the long-term costs and outcomes of PPCCM, payer coverage of PPCCM services may prevent future health care costs and improve patient cardiovascular outcomes. DISCLOSURES: No funding was received for the completion of this research. The authors have nothing to disclose. Study results were presented as an abstract at the AMCP 2021 Virtual, April 12-16, 2021.

Factors influencing the degree of physician-pharmacists collaboration within governmental hospitals of Jigjiga Town, Somali National Regional State, Ethiopia, 2020

BACKGROUND

Collaboration is the way to deliver the desired health outcome for the patients or service users in the healthcare. Inter-professional collaboration can improve medication safety, patient outcome and minimize healthcare costs. This study aimed to explore the degree of collaboration and factors influencing collaboration between physicians and pharmacists within the public hospitals of Jigjiga town, Somali National Regional State, Ethiopia, 2020.

METHODS

A cross-sectional study qualitative was conducted among 149 participants in the two governmental hospitals of the Jigjiga town with a response rate of 79.87%. The collaborative working relationship model and the physician-pharmacist collaborative instrument with three main exchange domains (trustworthiness, role specification, and relationship initiation) and collaborative care items were used. An independent sample t-test was used to compute the differences of the mean scores of physician-pharmacist collaborative instrument domains and collaborative care. Separate multiple regression was employed to assess factors influencing collaborative care for pharmacists and physicians.

RESULTS

This study showed that pharmacists reported higher mean of collaborative care (10.66 ± 4.75) than physicians (9.17 ± 3.92). The multiple regression indicated that area of practice influence both professionals' collaborative practice. A significant association between collaborative care and the two PPCI domains (trustworthiness and relationship initiation for the physicians; role specification and relationship initiation for pharmacists) was established.

CONCLUSIONS

The study showed that the collaboration between the physicians and pharmacists was sub-optimal and the exchange variables had a significant influence on their collaboration.

RECOMMENDATION

Physicians and pharmacists need to exert more efforts to enhance this collaboration. Further qualitative study might be needed to search for factors affecting, barriers and how to develop collaborative practice.

Impact of a clinical pharmacist on provider prescribing patterns in a primary care clinic

BACKGROUND

Sodium-glucose transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) agonists have demonstrated beneficial outcomes in patients with type 2 diabetes at high cardiovascular risk. Unfortunately, these agents are still underutilized in primary care practice. A clinical pharmacist was embedded at a primary care clinic to provide diabetes and hypertension management under a collaborative practice agreement with a supervising physician.

OBJECTIVES

This study will evaluate whether the presence of an embedded pharmacist in a primary care clinic affects prescribing patterns of novel, evidence-based diabetes therapies.

METHODS

We abstracted information on SGLT2 inhibitor and GLP-1 agonist prescribing patterns from 3 primary care clinics across 2 time periods as a single-center, retrospective cohort study. We used a difference-in-difference analysis to compare prescription rates and assess the impact of embedding the pharmacist into clinical practice. Prescriptions written by the pharmacist were excluded.

RESULTS

Across all 3 clinics, 1309 and 1489 patients were included in the pre-intervention and postintervention periods, respectively. The percentage of patients prescribed either an SGLT2 inhibitor or GLP-1 agonist, similar between both groups at baseline, rose to 11.6% in the nonintervention clinics and 15.0% in the intervention clinic. There was a statistically significant increase in SGLT2 inhibitor and GLP-1 agonist prescribing in the intervention clinic compared with nonintervention clinics (P = 0.034). This change in prescribing patterns appeared even greater when excluding prescribers who were not present during both pre-intervention and postintervention periods (P = 0.009).

CONCLUSION

The presence of a pharmacist is associated with increased SGLT2 inhibitor and GLP-1 agonist prescribing within a clinic, even in patients not seen directly by the pharmacist. These results suggest that an on-site clinical pharmacist providing care for patients with diabetes may indirectly influence the prescribing behavior of co-located primary care providers, increasing the adoption of novel noninsulin diabetic medications.

Meta-analysis of pharmacist-led and pharmacist-physician intervention on blood pressure control

Effective intervention is a significant component in the improvement of blood pressure control and patient adherence. Blood pressure control includes different self-monitoring techniques, mobile health monitoring, or healthcare professionals’ interventions. This study aims to compare, analyze, and interpret the effectiveness of pharmacist-physician collaboration and pharmacist- led interventions. Meta-analysis was performed using MEDLINE via PubMed, EMBASE, EBSCO, Web of Science, Scopus, and the Cochrane Library databases between 2008-2018. Of the 51 relevant systematic reviews identified, 15 were of sufficient quality and included in the data synthesis. The breakdown of the 15 included 7 (n=2026) pharmacist and 8 pharmacist-physician interventions (n=2361). The impact of pharmacist-physician collaboration and pharmacist-led interventions on Systolic Blood Pressure was –8.22 (–11.01; –5.42) (P<0.01) and –7.68 (–9.30; –6.06) (P=0.35), respectively. On the other hand, similar correlation for Diastolic Blood Pressure for the impact of pharmacist-physician collaboration and pharmacist-led interventions was –3.55 (–4.54; –2.55) (P=0.49) and –2.58 (–3.76; –1.39) (P=0.24), respectively. These results suggest that both interventions are effective for blood pressure control. However, when two meta-analyses were compared, it was found that pharmacist-physician collaboration was more effective than pharmacist-led interventions. This finding highlights the importance of multidisciplinary approaches during blood pressure control procedures. When a holistic view is considered; especially cost-effectiveness, future studies must be diversified to encompass a broader context and impact analysis.

Pharmacists' Perspectives on Interprofessional Collaboration with Physicians in Poland: A Quantitative Study

Over the years, many studies have emphasized the pharmacist's importance as part of the patient care team. Still, the interprofessional collaboration between physicians and pharmacists in their everyday work seems rare. Therefore, this study aimed to investigate the types of contact between them, possible mutual collaboration, and barriers to implementation. This study was conducted from April to August 2020. The study group included licensed pharmacists working in community pharmacies in Poland (n = 207). The results show that, according to the respondents, physician-pharmacist contact mainly concerns formal aspects, such as correcting prescription errors. They occasionally communicate for other matters, such as consultation regarding drug availability and drug dosage. However, when asked to divide responsibilities between them and physicians, pharmacists indicate areas that should involve interprofessional collaboration, e.g., monitoring adverse drug reactions, analysis of multi-drug therapy, and checking the regularity of taking medications. They indicated the lack of specific collaboration rules, limited willingness to establish relationships and low mutual respect and trust among existing barriers. It is worth considering the possibility of overcoming these barriers provided by interprofessional education in order to develop communication skills and build relationships based on respect.

Physician-pharmacist collaborative management in patients after percutaneous coronary intervention: a retrospective propensity score matching cohort study

AIM

Evaluate the effect of the Physician-Pharmacist Collaborative Management (PPCM) practice model in patients after percutaneous coronary intervention (PCI).

METHOD

A retrospective cohort study was conducted in post-PCI patients. The study enrolled patients who underwent PCI at our hospital from May 1, 2018, to January 31, 2020. Patients were divided into two groups: the PPCM group if they utilized the Complex Coronary Interventions Medication Therapy Management (CCI-MTM) clinic and the usual care (UC) group if they used the physician-only cardiology clinic. Patients had clinic visits monthly, and data were analyzed after 6-months of follow-up. A propensity score matching (PSM) method was used to control confounding bias between groups.

RESULTS

A total of 727 patients met the inclusion criteria, including 67 patients in the PPCM group and 660 patients in the UC group. Using the 1:2 nearest neighbor matching method, 61 pairs were successfully matched; this included 61 patients in the PPCM group and 122 patients in the UC group. The proportion of patients reaching both LDL-C (73.8% versus 41.0%, P < 0.001) and heart rate (14.8% versus 4.1%, P = 0.007) goals in the PPCM was higher compared to the UC group. The median time to achieving the goal LDL-C was shorter in the PPCM group (31 days versus 126 days, P = 0.001). The utilization rates of [Formula: see text]-receptor blockers (73.8% versus 56.6%, P = 0.005) and ACEIs or ARBs (72.1% versus 56.6%, P = 0.018) were higher in the PPCM group compared to the UC group. There was no significant difference in adverse drug events between the two groups (P > 0.05). All recommendations to resolve drug-related problems were accepted by the physicians and patients.

CONCLUSION

The pharmaceutical care provided by the pharmacist in the PPCM clinic improved risk factor control and increased the utilization of preventive drugs in post-PCI patients.

Primary Care of Adult Patients After Stroke: A Scientific Statement From the American Heart Association/American Stroke Association

Primary care teams provide the majority of poststroke care. When optimally configured, these teams provide patient-centered care to prevent recurrent stroke, maximize function, prevent late complications, and optimize quality of life. Patient-centered primary care after stroke begins with establishing the foundation for poststroke management while engaging caregivers and family members in support of the patient. Screening for complications (eg, depression, cognitive impairment, and fall risk) and unmet needs is both a short-term and long-term component of poststroke care. Patients with ongoing functional impairments may benefit from referral to appropriate services. Ongoing care consists of managing risk factors such as high blood pressure, atrial fibrillation, diabetes, carotid stenosis, and dyslipidemia. Recommendations to reduce risk of recurrent stroke also include lifestyle modifications such as healthy diet and exercise. At the system level, primary care practices can use quality improvement strategies and available resources to enhance the delivery of evidence-based care and optimize outcomes.

A De Novo Pharmacist-Family Physician Collaboration Model in a Family Medicine Clinic in Alberta, Canada

Collaborative practice in health-care has proven to be an effective and efficient method for the management of chronic diseases. This study describes a de novo collaborative practice between a pharmacist and a family physician. The primary objective of the study is to describe the collaboration model between a pharmacist and family physician. The secondary objective is to describe the pharmacist workload. A list of patients who had at least one interaction with the pharmacist was generated and printed from the electronic medical record. There were 389 patients on the patient panel. The pharmacist had at least one encounter with 159 patients. There were 83 females. The most common medical condition seen by the pharmacist was hypertension. A total of 583 patient consultations were made by the pharmacist and 219 of those were independent visits. The pharmacist wrote 1361 prescriptions. The expanded scope of practice for pharmacists in Alberta includes additional prescribing authority. The pharmacists’ education and clinical experience gained trust from the family physician. These, coupled with the family physician’s previous positive experience working with pharmacists made the collaboration achievable.

Interprofessional education and collaborative practice in Kuwait: attitudes and perceptions of health sciences students

Interprofessional education (IPE) prepares health students to become collaboration-ready healthcare professionals. Assessing students' baseline attitudes toward IPE and collaborative practice is essential to inform development of IPE curricula. Kuwait University Health Sciences Center (HSC) is early in its IPE journey but is planning to join the broader global movement toward IPE. A cross-sectional survey was conducted to explore the attitudes of HSC students from Faculties of Medicine, Dentistry, Pharmacy, and Allied Health Sciences toward collaborative practice and IPE at early and late stages of study. A total of 770 students completed the survey (81.1% response rate). Students expressed positive attitudes toward interprofessional healthcare teams and IPE (median [IQR] overall attitudes were rated 4.0 [1.0] and 4.0 [2.0], respectively, on a scale of 5). Overall attitudes toward both scales were significantly more positive among pharmacy students than students from other faculties (p < .001). Final-year students reported more positive attitudes toward healthcare teams than early- and middle-year students, while early- and final-year students expressed more positive attitudes toward IPE than middle-year students (p < .001). There were no significant differences in overall attitudes between female and male students toward the two scales (p > .05). These findings have implications for engaging students from different professions in IPE initiatives.

Targeting of uncontrolled hypertension in the emergency department (TOUCHED): Design of a randomized controlled trial

BACKGROUND

Uncontrolled or undiagnosed hypertension (HTN) is estimated to be as high as 46% in emergency departments (EDs). Uncontrolled HTN contributes significantly to cardiovascular morbidity and disproportionately affects communities of color. EDs serve high risk populations with uncontrolled conditions that are often missed by other clinical settings and effective interventions for uncontrolled HTN in the ED are critically needed. The ED is well situated to decrease the disparities in HTN control by providing a streamlined intervention to high risk populations that may use the ED as their primary care.

METHODS

Targeting of UnControlled Hypertension in the Emergency Department (TOUCHED), is a two-arm single site randomized controlled trial of 770 adults aged 18-75 presenting to the ED with uncontrolled HTN comparing (1) usual care, versus (2) an Educational and Empowerment (E2) intervention that integrates a Post-Acute Care Hypertension Consultation (PACHT-c) with a mobile health BP self-monitoring kit. The primary outcome is differences in mean systolic blood pressure (SBP) at 6-months post enrollment. Secondary outcomes include differences in mean SBP and mean diastolic BP (DBP) at 3-months and mean DBP at 6-months. Additionally, improvement in cardiovascular risk score, medication adherence, primary care engagement, and HTN knowledge will also be assessed as part of this study.

CONCLUSIONS

The TOUCHED trial will be instrumental in determining the effectiveness of a brief ED-based intervention that is portable to other urban EDs with high-risk populations.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03749499.

Dissemination of a telehealth cardiovascular risk service: The CVRS live protocol

BACKGROUND

Medical clinics are increasingly hiring clinical pharmacists to improve management of cardiovascular disease (CVD). However, the limited number of clinical pharmacists employed in a clinic may not impact the large number of complex patients needing the services. We have developed a remote telehealth service provided by clinical pharmacists to complement CVD services provided by on-site clinical pharmacists and aid sites without a clinical pharmacist. This cardiovascular risk service (CVRS) has been studied in two NIH-funded trials, however, we identified barriers to optimal intervention implementation. The purpose of this study is to examine how to implement the CVRS into medical offices and see if the intervention will be sustained.

METHODS

This is a 5-year, pragmatic, cluster-randomized clinical trial in 13 primary care clinics across the US. We randomized clinics to receive CVRS or usual care and will enroll 325 patient subjects and 288 key stakeholder subjects. We have obtained access to the electronic medical records (EMRs) of all study clinics to recruit subjects and provide the pharmacist intervention. The intervention is staggered so that after 12 months, the usual care sites will receive the intervention for 12 months. Follow-up will be accomplished though medical record abstraction at baseline, 12 months, 24 months, and 36 months.

CONCLUSIONS

This study will enroll subjects through 2021 and results will be available in 2024. This study will provide unique information on how the CVRS provided by remote clinical pharmacists can be effectively implemented in medical offices, many of which already employ on-site clinical pharmacists.

CLINICAL TRIAL REGISTRATION INFORMATION

NCT03660631: http://clinicaltrials.gov/ct2/show/NCT03660631.

Impact of interprofessional collaboration on chronic disease management: Findings from a systematic review of clinical trial and meta-analysis

Improvement of chronic disease management demands effective collaborative relationships between health and social-care which is achieved through teamwork. Interprofessional Education (IPE) and Interprofessional Collaboration (IPC) are recognized as essential for the delivery of effective and efficient healthcare. Although IPC and IPE are key components of primary care, evidence of studies evaluating how an IPE intervention prior to IPC improved chronic patient outcomes remains scarce. The aim of this study was to assess the impact of IPC interventions on the management of chronic patients compared to usual care. A systematic review and meta-analysis of Randomized Controlled Trials (RCTs) on IPC interventions on chronicity management and their impact on clinical and process outcomes was conducted. Of the 11,128 papers initially retrieved, 23 met the inclusion criteria. Meta-analyses results showed the reduction of systolic blood pressure (Mean Difference (MD) -3.70; 95 % CI -7.39, -0.01), glycosylated hemoglobin (MD -0.20; 95 % CI -0.47, -0.07), LDL cholesterol (MD -5.74; 95 % CI -9.34, -2.14), diastolic blood pressure (MD -1.95; 95 % CI -3.18, -0.72), days of hospitalization (MD -2.22; 95 % CI -4.30, -0.140). A number of positive findings for outcomes related to IPC were found reflecting an improvement of quality of care and an enhancement in the delivery of patient-centered and coordinated care. Moreover, the need for a purposeful systemic approach linking interprofessional education with interprofessional collaboration and patient health and wellbeing is necessary.

Impact of clinical pharmacist-led diabetes management clinic on health outcomes at an academic hospital in Riyadh, Saudi Arabia: A prospective cohort study

BACKGROUND

Diabetes prevalence is estimated to reach 20.6% by 2030. Studies have illustrated main reasons for uncontrolled patients and concluded: low level of awareness, limited access to healthcare providers, and lack of cooperation between different disciplines. The role of pharmacists has been proven to improve patient-related outcomes, including an improvement in HgA1C readings between 0.54% and 1.6%.

OBJECTIVES

This study was conducted to evaluate diabetes-related health outcomes in a pharmacist-led diabetes clinic in terms of HgbA1C level, guideline-recommended routine screenings, medication adherence, and biomarkers of other comorbidities.

METHOD

A prospective cohort study conducted from August 2017 until July 2018 at an academic hospital. The pharmacist-led diabetes clinic was providing the service for a half-day per week. The study included all adult diabetic patients referred to the pharmacist-led clinic and had -at least- three 3-month apart follow-up visits with no exclusions. The baseline assessments for patients receiving routine diabetic care was performed using HgbA1C level, blood pressure, lipid and thyroid panel, eye and foot examinations, preventive measures, and adherence. The baseline results were compared to the follow-up results thereafter. A descriptive analysis was used to report the differences between intervals. Main outcome measure: (a) Reduction in HgbA1c levels, (b) intervention made by clinical pharmacists in an outpatient setting.

RESULT

The study included thirty-five patients. The mean ± SD age was 56 ± 10 years old. At baseline, mean HgbA1C was 9.5% ± 1.3%. HgbA1C was ≥10% for 13 patients. Albuminuria was never previously assessed for 14 patients. Twenty percent were receiving incorrect dose compared to the guideline-recommended statin therapy. By the end of study, mean HgbA1C had significantly improved to be 8.3% ± 1.4% (p = 0.0004). Nine patients achieved their HgbA1C goal of <7%. All patients were assessed for albuminuria, and managed accordingly. Thirty-two patients were eligible to receive statin therapy, and prescribed appropriate doses. Additionally, peripheral neuropathy was assessed for all cohort, and seven patients received recommended vaccinations.

CONCLUSION

Involving clinical pharmacists in diabetes management clinic can provide valuable services, help patients to adhere to the therapeutic plans, and assist physicians to achieve better treatment outcomes.

A pharmacist intervention for monitoring and treating hypertension using bidirectional texting: PharmText BP

BACKGROUND

New approaches are needed to better monitor blood pressure (BP) between physician visits, especially for patients in rural areas or for those who lack transportation. We have developed a custom-built bi-directional texting platform for home BP measurements that can then be managed by clinical pharmacists located remotely. The purpose of this study is to evaluate whether the BP texting approach combined with a pharmacist-based intervention improves BP management and to determine if the approach is cost effective.

METHODS

This study is a randomized, prospective trial in four primary care offices that serve patients in rural areas. Subjects will receive standardized research BP measurements at baseline, 6 and 12 months. The primary outcome will be differences between the intervention and control group in mean systolic BP at 12 months. Secondary outcomes will include systolic BP at 6 months; diastolic BP at 6 and 12 months, number of medication changes and costs.

CONCLUSIONS

This study plans to enroll subjects through 2022, follow-up will be completed in 2023 and results will be available in 2024. This study will provide information on whether a combined approach using texting of home BP values and a pharmacist-based telehealth services can improve BP control.

Impact of pharmacist intervention for blood pressure control in patients with chronic kidney disease: A meta-analysis of randomized clinical trials

WHAT IS KNOWN AND OBJECTIVE

Hypertension (HTN) and chronic kidney disease (CKD) are recognized as silent killers because they are asymptomatic conditions that contribute to the burden of multiple comorbidities. The achievement of a blood pressure (BP) goal can dramatically reduce the risks of CKD. In this study, we aimed to assess the effectiveness of pharmacist intervention on BP control in patients with CKD and evaluate the usefulness of home-based BP telemonitoring.

METHODS

The terms "chronic kidney disease," "pharmacist," "BP" and "randomized controlled trial (RCT)" were used five databases to search for information regarding pharmacist intervention on BP control in patients with CKD. The inclusion criteria were as follows: (a) studies for adult patients with uncontrolled HTN and (b) studies with adequate data for meta-analysis. The primary outcome was an evaluation of achievement of BP goal in patients with CKD. The secondary outcome was usefulness of home-based BP telemonitoring by pharmacists in patients with CKD.

RESULTS AND DISCUSSION

Six RCTs were identified and included in the meta-analysis with a total of 2573 patients (mean age 66.0 years and 63.9% male). Pharmacist interventions resulted in significantly better BP control vs usual care (OR = 1.53, 95% CI = 1.15-2.04, P < .01). Pharmacist interventions using home-based BP telemonitoring were significantly superior to control/usual care (OR = 2.03, 95% CI = 1.49-2.77, P < .01), whereas pharmacist interventions without home-based BP telemonitoring did not significantly improve BP control compared to that with control/usual care (OR = 1.30, 95% CI = 0.97-1.75, P = .08). Home-based BP telemonitoring supported team-based care for HTN in these studies. In addition, patient self-monitoring with telemedicine devices might enhance patients' abilities to manage their condition by pharmacist instruction.

WHAT IS NEW AND CONCLUSION

The findings of this meta-analysis showed that pharmacist interventions with home-based BP telemonitoring improve BP control among adult patients with CKD.

The clinical impact of pharmacist services on mental health collaborative teams: A systematic review

OBJECTIVE

To evaluate the clinical impact of mental health collaborative teams that include pharmacists.

DATA SOURCES

PubMed, PsychInfo, Clinialtrials.gov, International Pharmaceutical Abstracts.

STUDY SELECTIONS

Studies in which pharmacists were part of a mental health collaborative team (defined as 2 or more health care providers working together to provide enhanced mental health care services to patients), mental health clinical outcomes were measured with a validated tool, and the articles were written in English were included. Articles were searched from database inception to July 2019 and were excluded if a quantifiable comparison of mental health clinical outcomes was not included or collaboration was not described.

DATA EXTRACTION

Two authors independently screened titles and abstracts for relevance. Full-text articles that potentially met inclusion criteria were retrieved, read, and evaluated for inclusion using the eligibility criteria.

RESULTS

All 9 included studies reported improvements in mental health clinical outcomes when using collaborative teams that included pharmacists. Depression (n = 8) and post-traumatic stress disorder (PTSD) (n = 1) were the mental health conditions included in the studies. Overall, 5 of 7 of the randomized controlled trials (RCTs) had statistically significant improvement in mental health clinical outcomes between the intervention groups, which included the collaborative teams and a "usual care" groups, which did not. Four of the 5 studies were set in Veterans Affairs (VA) clinics. The 2 non-RCT pre-post studies showed improvements in clinical outcomes but did not achieve statistical significance.

CONCLUSION

Evidence shows that collaborative teams that include pharmacists are effective at improving mental health outcomes in patients with depression and PTSD. Future studies should include non-VA settings and other mental health conditions to understand pharmacists' impact more broadly in mental health collaborative teams. Clarifying and understanding the overlapping roles and responsibilities of members of the team may be the next step to continue improving mental health clinical outcomes.

Impact of pharmacist interventions on drug-related problems in general surgery patients: a randomised controlled trial

OBJECTIVES

The inappropriate use of medications is harmful and is a common issue in hospitalised patients. Patients hospitalised in general surgery wards are usually at high risk for drug-related problems (DRPs). This randomised controlled trial aimed to explore the value of a pharmaceutical care service conducted in general surgery wards in the identification and reduction of DRPs in comparison with standard medical care.

METHODS

This study was conducted in general surgery wards including abdominal, cardiovascular, vascular, endocrine, orthopaedic and oncological surgeries at one of the largest teaching hospitals in Jordan over a period of 6 months. Recruited patients were randomised into intervention or control groups. Clinical pharmacists assessed patients' DRPs and submitted recommendations to resolve the identified DRPs in the intervention group.

RESULTS

Patients in the intervention group (n=63) and the control group (n=60) had a mean age of 55±14.4 years, with 52.0% being women. A total of 1062 DRPs were identified, with a mean of 8.6±3.6 per patient (intervention group, 8.65±4.2; control group, 8.62±2.6; p=0.56). The commonly identified DRPs included safety (20.2%) and efficacy (19.0%) issues. The acceptance rate for pharmacists' recommendations by physicians was very high (90%) with a good DRP correction rate of 58.9% during patients' hospital stay. The value of pharmaceutical care was significantly reflected in the achievement of the therapeutic outcomes and prevention of morbidity (resolved/improved or prevented) of 68.2% (24.2%+44%) in the intervention group compared with 19.2% (12.4%+6.8%) in the control group (p<0.001).

CONCLUSIONS

This study shows that DRPs are common among general surgery patients in Jordan, especially those related to drug safety and efficacy. Pharmacists' recommendations contributed substantially to resolving most of the identified DRPs and had a significant impact on improving medications used in general surgery patients.

Improving Medication Adherence in an ACO Primary Care Office With a Pharmacist-Led Clinic: A Report From the ACORN SEED

BACKGROUND

As health care moves into the era of value-based medicine, both ambulatory and acute settings are being held accountable for the quality of care provided to patients. Previous studies have shown improved clinical outcomes through medication therapy management (MTM) due to improved medication adherence.

OBJECTIVE

The purpose of this study is to assess the effects of a pharmacist-led MTM clinic in an accountable care organization (ACO) affiliated primary care office on adherence to renin-angiotensin system (RAS) antagonists, diabetic medications, and/or statin medications reported through Healthcare Effectiveness Data and Information Set (HEDIS) Medicare Star Ratings.

METHODS

In this retrospective cohort study, data were collected via chart review of pharmacist-led MTM patient interviews and follow-ups between October 2015 and April 2017. Eligible patients were Humana HMO Medicare beneficiaries, with at least one chronic disease state, for which they were treated with a RAS antagonist, statin, or diabetic medication. The primary outcome of this investigation was a change in Star Rating scores for medication adherence to RAS antagonists, diabetic medications, and statins from pre- and postpharmacist MTM intervention.

RESULTS

A total of 102 patients were referred to the MTM clinic. Out of these, 32 had a follow-up visit, resulting in a total of 25 interventions. One year prior to MTM clinic implementation, most Star Ratings were consistently 3 (out of 5) for RAS antagonists, diabetic medications, and statins. Postintervention, ratings increased to 4 or 5 across these categories. Conclusion: Implementing a pharmacist-led MTM clinic in the ACO primary care setting improves Medicare Star Ratings in patients with chronic conditions.

Clinical and economic outcomes of hospital pharmaceutical care: a systematic review and meta-analysis

BACKGROUND

Hospital clinical pharmacists have been working in many countries for many years and clinical pharmaceutical care have a positive effect on the recovery of patients. In order to evaluate the clinical effectiveness and economic outcomes of clinical pharmaceutical care, relevant clinical trial studies were reviewed and analysed.

METHODS

Two researchers searched literatures published from January 1992 to October 2019, and screened them by keywords like pharmaceutical care, pharmaceutical services, pharmacist interventions, outcomes, effects, impact, etc. Then, duplicate literatures were removed and the titles, abstracts and texts were read to screen literatures according to inclusion and exclusion criteria. Key data in the literature were extracted, and Meta-analysis was conducted using the literature with common outcome indicators.

RESULTS

A total of 3299 articles were retrieved, and 42 studies were finally included. Twelve of them were used for meta-analysis. Among the 42 studies included, the main results of pharmaceutical care showed positive effects, 36 experimental groups were significantly better than the control group, and the remaining 6 studies showed mixed or no effects. Meta-analysis showed that clinical pharmacists had significant effects on reducing systolic blood pressure and diastolic blood pressure and shortening hospitalization days (P < 0.05), but no statistical significance in reducing medical costs (P > 0.05).

CONCLUSION

Clinical pharmacists' pharmaceutical care has a significant positive effect on patients' clinical effects, but has no significant economic effect.

Community pharmacist workflow: Space for Pharmacy-based Interventions and Consultation TimE study protocol

BACKGROUND

Pharmacists' roles are expanding to delivering a wider set of professional services including medication management optimisation, vaccinations and screening services. Robust research determining whether pharmacists have the capacity to offer such services in the Australian community pharmacy setting is lacking. This protocol details a mixed methods study that investigates the variation in pharmacists' daily tasks and the workspace they work in as a measure of their workload capacity for expanding pharmacy services.

METHODS

An observational time and motion study will be conducted in up to twenty community pharmacies in metropolitan and rural regions of Australia. A trained observer will follow a pharmacist and record the type, location and duration of tasks undertaken over the course of their working day. Data will be collected and analysed using the electronic Work Observation Method By Activity Timing (WOMBAT) tool. Pharmacists' work patterns will be described as time for each task, and by proportionating multitasking and interruptions. This information will be combined with workspace data collected using floor plans, photographs and a qualitative assessment of the working environment completed by the observer. Analysis will include heat-mapped floor plans visually highlighting pharmacist movements.

DISCUSSION

Pharmacists may provide solutions to the strained health workforce and system. There is limited quantitative evidence on whether pharmacists have the time or work setting to support such needs. The use of time and motion methodology is novel to Australian community pharmacy research, and the findings will provide a better understanding of pharmacists' capacity and work environment.

A Systematic Review of Network Studies Based on Administrative Health Data

Effective and efficient delivery of healthcare services requires comprehensive collaboration and coordination between healthcare entities and their complex inter-reliant activities. This inter-relation and coordination lead to different networks among diverse healthcare stakeholders. It is important to understand the varied dynamics of these networks to measure the efficiency of healthcare delivery services. To date, however, a work that systematically reviews these networks outlined in different studies is missing. This article provides a comprehensive summary of studies that have focused on networks and administrative health data. By summarizing different aspects including research objectives, key research questions, adopted methods, strengths and weaknesses, this research provides insights into the inherently complex and interlinked networks present in healthcare services. The outcome of this research is important to healthcare management and may guide further research in this area.

Modeling the Health and Budgetary Impacts of a Team-based Hypertension Care Intervention That Includes Pharmacists

OBJECTIVE

The objective of this study was to assess the potential health and budgetary impacts of implementing a pharmacist-involved team-based hypertension management model in the United States.

RESEARCH DESIGN

In 2017, we evaluated a pharmacist-involved team-based care intervention among 3 targeted groups using a microsimulation model designed to estimate cardiovascular event incidence and associated health care spending in a cross-section of individuals representative of the US population: implementing it among patients with: (1) newly diagnosed hypertension; (2) persistently (≥1 year) uncontrolled blood pressure (BP); or (3) treated, yet persistently uncontrolled BP-and report outcomes over 5 and 20 years. We describe the spending thresholds for each intervention strategy to achieve budget neutrality in 5 years from a payer's perspective.

RESULTS

Offering this intervention could prevent 22.9-36.8 million person-years of uncontrolled BP and 77,200-230,900 heart attacks and strokes in 5 years (83.8-174.8 million and 393,200-922,900 in 20 years, respectively). Health and economic benefits strongly favored groups 2 and 3. Assuming an intervention cost of $525 per enrollee, the intervention generates 5-year budgetary cost-savings only for Medicare among groups 2 and 3. To achieve budget neutrality in 5 years across all groups, intervention costs per person need to be around $35 for Medicaid, $180 for private insurance, and $335 for Medicare enrollees.

CONCLUSIONS

Adopting a pharmacist-involved team-based hypertension model could substantially improve BP control and cardiovascular outcomes in the United States. Net cost-savings among groups 2 and 3 make a compelling case for Medicare, but favorable economics may also be possible for private insurers, particularly if innovations could moderately lower the cost of delivering an effective intervention.

No difference in medication regimes and dosing in study participants with and without blood pressure control: longitudinal data of the population-based Heinz Nixdorf Recall Study

BACKGROUND

To achieve blood pressure (BP) control adequate dosing of first-line antihypertensive medications is recommended in addition to life-style changes. Given observations that dosing of antihypertensive agents is frequently insufficient, we compared the changes of BP control rates and antihypertensive drug regimens in a prospective German population using a new strategy to analyze medication dosing.

METHODS

This analysis is based on data of the baseline (2000-2003) and the first follow-up examination (2005-2008) of the population-based Heinz Nixdorf Recall study. Participants with hypertension at baseline (BP ≥140/90 mmHg or at least one antihypertensive agent) who participated in both examinations were included.

RESULTS

Of the 4157 participants, 2289 (55.1%) had hypertension at baseline. The prevalence of participants on antihypertensive agents was 60.3% at baseline and increased to 75.1% at follow-up. The mean number of antihypertensive agents was 2 [±1 SD (standard deviation)] initially and at follow-up. The prevalence of medication-controlled BP did not improve over time (baseline: 54.5%, follow-up: 56.5%). When stratifying by medication-controlled BP, the medication dosing rate slightly increased over time without differences between groups [controlled versus uncontrolled BP: 40.9 versus 46.2% (baseline); 50.1 versus 51.9% (follow-up)].

CONCLUSION

Although the prevalence of antihypertensive medication use increased in the study period, the BP control rate did not. In contrast to clinical reasoning, participants with uncontrolled BP did neither receive more agents nor higher dosing despite outcome-relevant hypertension. Our approach to analyze medication dosing suggests a potential to improve cardiovascular outcomes by increasing dosages of antihypertensive agents.

Systematic Review and Meta-Analysis of Medication Reviews Conducted by Pharmacists on Cardiovascular Diseases Risk Factors in Ambulatory Care

Background

Pharmacists‐led medication reviews (MRs) are claimed to be effective for the control of cardiovascular diseases; however, the evidence in the literature is conflicting. The main objective of this meta‐analysis was to analyze the impact of pharmacist‐led MRs on cardiovascular disease risk factors overall and in different ambulatory settings while exploring the effects of different components of MRs.

Methods and Results

Searches were conducted in PubMed, Web of Science, Embase, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library Central Register of Controlled Trials database. Randomized and cluster randomized controlled trials of pharmacist‐led MRs compared with usual care were included. Settings were community pharmacies and ambulatory clinics. The classification used for MRs was the Pharmaceutical Care Network Europe as basic (type 1), intermediate (type 2), and advanced (type 3). Meta‐analyses in therapeutic goals used odds ratios to standardize the effect of each study, and for continuous data (eg, systolic blood pressure) raw differences were calculated using baseline and final values, with 95% CIs. Prediction intervals were calculated to account for heterogeneity. Sensitivity analyses were conducted to test the robustness of results. Meta‐analyses included 69 studies with a total of 11 644 patients. Sample demographic characteristics were similar between studies. MRs increased control of hypertension (odds ratio, 2.73; 95% prediction interval, 1.05–7.08), type 2 diabetes mellitus (odds ratio, 3.11; 95% prediction interval, 1.17–5.88), and high cholesterol (odds ratio, 1.91; 95% prediction interval, 1.05–3.46). In ambulatory clinics, MRs produced significant effects in control of diabetes mellitus and cholesterol. For community pharmacies, systolic blood pressure and low‐density lipoprotein values decreased significantly. Advanced MRs had larger effects than intermediate MRs in diabetes mellitus and dyslipidemia outcomes. Most intervention components had no significant effect on clinical outcomes and were often poorly described. CIs were significant in all analyses but prediction intervals were not in continuous clinical outcomes, with high heterogeneity present.

Conclusions

Intermediate and advanced MRs provided by pharmacists may improve control of blood pressure, cholesterol, and type 2 diabetes mellitus, as statistically significant prediction intervals were found. However, most continuous clinical outcomes failed to achieve statistical significance, with high heterogeneity present, although positive trends and effect sizes were found. Studies should use a standardized method for MRs to diminish sources of these heterogeneities.

Cost-Effectiveness and Challenges of Implementing Intensive Blood Pressure Goals and Team-Based Care

PURPOSE OF REVIEW

Review the effectiveness, cost-effectiveness, and implementation challenges of intensive blood pressure (BP) control and team-based care initiatives.

RECENT FINDINGS

Intensive BP control is an effective and cost-effective intervention; yet, implementation in routine clinical practice is challenging. Several models of team-based care for hypertension management have been shown to be more effective than usual care to control BP. Additional research is needed to determine the cost-effectiveness of team-based care models relative to one another and as they relate to implementing intensive BP goals. As a focus of healthcare shifts to value (i.e., cost, effectiveness, and patient preferences), formal cost-effectiveness analyses will inform which team-based initiatives hold the highest value in different healthcare settings with different populations and needs. Several challenges, including clinical inertia, financial investment, and billing restrictions for pharmacist-delivered services, will need to be addressed in order to improve public health through intensive BP control and team-based care.

Effectiveness of Shared Decision-making for Diabetes Prevention: 12-Month Results from the Prediabetes Informed Decision and Education (PRIDE) Trial

IMPORTANCE

Intensive lifestyle change (e.g., the Diabetes Prevention Program) and metformin reduce type 2 diabetes risk among patients with prediabetes. However, real-world uptake remains low. Shared decision-making (SDM) may increase awareness and help patients select and follow through with informed options for diabetes prevention that are aligned with their preferences.

OBJECTIVE

To test the effectiveness of a prediabetes SDM intervention.

DESIGN

Cluster randomized controlled trial.

SETTING

Twenty primary care clinics within a large regional health system.

PARTICIPANTS

Overweight/obese adults with prediabetes (BMI ≥ 24 kg/m2 and HbA1c 5.7-6.4%) were enrolled from 10 SDM intervention clinics. Propensity score matching was used to identify control patients from 10 usual care clinics.

INTERVENTION

Intervention clinic patients were invited to participate in a face-to-face SDM visit with a pharmacist who used a decision aid (DA) to describe prediabetes and four possible options for diabetes prevention: DPP, DPP ± metformin, metformin only, or usual care.

MAIN OUTCOMES AND MEASURES

Primary endpoint was uptake of DPP (≥ 9 sessions), metformin, or both strategies at 4 months. Secondary endpoint was weight change (lbs.) at 12 months.

RESULTS

Uptake of DPP and/or metformin was higher among SDM participants (n = 351) than controls receiving usual care (n = 1028; 38% vs. 2%, p < .001). At 12-month follow-up, adjusted weight loss (lbs.) was greater among SDM participants than controls (- 5.3 vs. - 0.2, p < .001).

LIMITATIONS

Absence of DPP supplier participation data for matched patients in usual care clinics.

CONCLUSIONS AND RELEVANCE

A prediabetes SDM intervention led by pharmacists increased patient engagement in evidence-based options for diabetes prevention and was associated with significantly greater uptake of DPP and/or metformin at 4 months and weight loss at 12 months. Prediabetes SDM may be a promising approach to enhance prevention efforts among patients at increased risk.

TRIAL REGISTRATION

This study was registered at clinicaltrails.gov (NCT02384109)).

Advancing Pharmacist Collaborative Care within Academic Health Systems

INTRODUCTION

The scope of pharmacy practice has evolved over the last few decades to focus on the optimization of medication therapy. Despite this positive impact, the lack of reimbursement remains a significant barrier to the implementation of innovative pharmacist practice models.

SUMMARY

We describe the successful development, implementation and outcomes of three types of pharmacist collaborative care models: (1) a pharmacist with physician oversight, (2) pharmacist-interprofessional teams and (3) physician-pharmacist teams. The outcome measurement of these pharmacist care models varied from the design phase to patient volume measurement and to comprehensive quality dashboards. All of these practice models have been successfully funded by affiliated health systems or grants.

CONCLUSIONS

The expansion of pharmacist services delivered by clinical faculty has several benefits to affiliated health systems: (1) significant improvements in patient care quality, (2) access to experts in specialty areas, and (3) the dissemination of outcomes with national and international recognition, increasing the visibility of the health system.

Pharmacist-Delivered Patient Care in an Interdisciplinary Team-Based Institutional Palliative Care Clinic, 2012 to 2018

Palliative care services offered in the United States have grown substantially since the year 2000. These types of services have been shown to improve a patient's quality of life when presented with a serious or life-threatening disease or illness. An important characteristic of a quality palliative care service is the presence of an interdisciplinary team to utilize different areas of expertise to address multiple aspects of patient care. An important member of this team is the pharmacist. The services presented in this interprofessional education and practice guide describe pharmacist-delivered palliative care services offered in an institutional ambulatory palliative care setting from 2012 to 2018.

Cluster-Randomized Trial to Evaluate a Centralized Clinical Pharmacy Service in Private Family Medicine Offices

BACKGROUND

The use of clinical pharmacists in primary care has improved the control of several chronic cardiovascular conditions. However, many private physician practices lack the resources to implement team-based care with pharmacists. The purpose of this study was to evaluate whether a centralized, remote, clinical pharmacy service could improve guideline adherence and secondary measures of cardiovascular risk in primary care offices in rural and small communities.

METHODS AND RESULTS

This study was a prospective trial in 12 family medicine offices cluster randomized to either the intervention or usual care. The intervention was delivered for 12 months, and subjects had research visits at baseline and 12 months. The primary outcome was adherence to guidelines, and secondary outcomes included changes in key cardiovascular risk factors and preventative health measures. We enrolled 302 subjects. There was no improvement in the Guideline Advantage score from baseline to 12 months in the control group (64.7% versus 63.1%, respectively; P=0.21). There was a statistically significant improvement in the intervention group from 63.3% at baseline to 67.8% at 12 months (P=0.02). The estimated benefit of the intervention was 5.0%±2.4% (95% confidence interval=-0.5% to 10.4%; P=0.07). Several criteria were significantly better for intervention subjects, including appropriate statin therapy (P<0.001), body mass index, screening (P<0.001), and alcohol screening (P<0.001). Only 13.7% of subjects with diabetes mellitus had hemoglobin A1c at goal at baseline, and this increased to 30.8% and 21.0% in the intervention and control group, respectively, at 12 months (P=0.10).

CONCLUSIONS

The centralized, remote pharmacist intervention was successfully implemented. The improvements in outcomes were modest, in part because of higher than expected baseline guideline adherence. Future studies of this model should focus on patients with uncontrolled conditions at high risk for cardiovascular events.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT 01983813.