Pharmacist-physician collaborative care model and time to goal blood pressure in the uninsured population

A teamwork OSCE station - Encompassing shared decision making between a doctor, pharmacist and patient

BACKGROUND AND PURPOSE

Teamwork with a focus on incorporating interprofessional education (IPE) is a core skill taught in pharmacy curriculum. Including the patient in shared decision making has become a more empathetic and holistic approach to care. Teamwork skills and approaches are usually assessed by peers via group work.

EDUCATIONAL ACTIVITY AND SETTING

A teamwork Objective Structured Clinical Examination (OSCE) station was implemented in 2022 in two countries, conducted in final year pharmacy students where students had to solve a clinical scenario with a doctor and patient in the room and manage any resistances to therapy recommendations. Students were marked on their collaborative skills and how they articulated clinical evidence to justify their therapy recommendations to reach an optimal goal to suit the team. Perception data from students simulated patients and doctors were also collected.

FINDINGS

Across both countries (n = 414), the overall mean score was 79.1% (24.0%SD) across six different OSCE cases. Students generally struggled with the concept of engaging in a two-way conversation, and often presented their full recommendations without any breaks to confirm understanding or agreement. Simulated patients appreciated the OSCE showing a patient role in decision making. Simulated doctors valued the OSCE for its assessment of clinical justification in times of disagreement. Overall, 86.2% of students (n = 354) agreed or strongly agreed the station assessed their teamwork skills adequately.

SUMMARY

A teamwork OSCE station is a valuable assessment for assessing shared decision making skills and more work around prepare students to engage in two-way conversations is needed.

Introspective Learning From Interprofessional Virtual Grand Rounds

BACKGROUND

Interprofessional collaboration in health care settings improves patient safety and outcomes, yet collaboration among health professionals requires specific competencies and skills. Providing nursing students with interprofessional learning experiences with multiple health professions is possible yet challenging.

PROBLEM

Opportunities for effective online interprofessional learning are lacking.

APPROACH

This article explores nursing students' reflections on how an interprofessional learning experience, Virtual Grand Rounds (VGRs), influenced their personal development and provided meaningful learning that they can use in their practices as professional nurses. Thematic analysis was done on the open-ended questions in students' final reflection assignment.

OUTCOMES

Analysis of student reflections identified 5 learning themes including the value of teamwork and collaboration, the importance of communication skills, professional identity, plans to engage diverse health professions, and the desire for future learning.

CONCLUSIONS

Student reflections indicate the VGR was an effective method for nursing students to experience collaboration with multiple health professions without disrupting curriculums.

Measuring Interprofessional Collaboration's Impact on Healthcare Services Using the Quadruple Aim Framework: A Protocol Paper

Despite decades of research on the impact of interprofessional collaboration (IPC), we still lack definitive proof that team-based care can lead to a tangible effect on healthcare outcomes. Without return on investment (ROI) evidence, healthcare leaders cannot justifiably throw their weight behind IPC, and the institutional push for healthcare manpower reforms crucial for facilitating IPC will remain variable and fragmentary. The lack of proof for the ROI of IPC is likely due to a lack of a unifying conceptual framework and the over-reliance on the single-method study design. To address the gaps, this paper describes a protocol which uses as a framework the Quadruple Aim which examines the ROI of IPC using four dimensions: patient outcomes, patient experience, provider well-being, and cost of care. A multimethod approach is proposed whereby patient outcomes are measured using quantitative methods, and patient experience and provider well-being are assessed using qualitative methods. Healthcare costs will be calculated using the time-driven activity-based costing methodology. The study is set in a Singapore-based national and regional center that takes care of patients with neurological issues.

Questionnaire survey on pharmacists' roles among non- and health care professionals in medium-sized cities in Japan

Although the scope of pharmacists' work has expanded in Japan, people's perception of this is unclear. To contribute to medical care together with non- and health care professionals, clarifying the perceptions of these groups is important to best utilize pharmacist professionals. We conducted a cross-sectional questionnaire survey among non-health care professionals (n = 487) and nurses (n = 151), medical doctors (n = 133), and pharmacists (n = 204) regarding the work of pharmacists. The questionnaire comprised 56 items in four categories associated with the roles of pharmacists. For each questionnaire item, we performed logistic regression analysis to compare pharmacists' opinions with those of other professionals and non-health care professionals. Opinions were similar between pharmacists and nurses or medical doctors regarding "collecting patient information" and "providing drug information to patients." However, there were differences in perceptions regarding "medical collaboration" (nurses; 8/23 items, physicians; 11/23 items) and "community medicine" (nurses; 9/15 items, physicians; 11/15 items), and pharmacists themselves perceived greater roles related to health care collaboration and community health care. Perceptions of non-health care professionals were poorer than those of pharmacists in all categories (47/56 items). These results suggest that pharmacists must actively communicate to help others understand their specialty and build trusting relationships to improve patient care.

Centrally supported clinical pharmacist intervention to reduce clinical inertia in hypertension

PURPOSE

To assess the impact of a one-time hypertension (HTN)-focused clinical pharmacist intervention on the occurrence of clinical inertia and change in blood pressure (BP).

METHODS

This retrospective study included patients 18 to 89 years of age with a current diagnosis of HTN and average systolic BP of ≥150 mm Hg. Centralized outreach coordinators performed telephone outreach to patients to schedule an HTN-focused visit with their primary care provider (PCP) and forwarded outreach notes for half of these patients to clinical pharmacists embedded in an internal medicine clinic. The clinical pharmacists performed a one-time focused medication review and provided evidence-based recommendations to a patient's PCP prior to the scheduled appointment. The primary outcome was therapy intensification (medication adjustment or adherence discussion) as a measure of overcoming clinical inertia. Secondary outcomes were the mean changes in systolic and diastolic BP from preintervention values to 6-month follow-up in the intervention group versus the control group.

RESULTS

A total of 91 patients were included, and 34 of 47 intervention patients (72%) had therapy intensification at the HTN-focused PCP appointment, compared to 20 of 44 control patients (46%) (P =0.017). The mean (SD) systolic BP reductions from baseline were 12.26 (29.04) mm Hg and 6.97 (27.05) mm Hg for the intervention and control groups, respectively (P =0.427), with diastolic BP reductions of 3.83 (13.14) mm Hg and 1.35 (10.60) mm Hg, respectively (P =0.380).

CONCLUSION

A collaborative model involving centralized outreach coordinators and embedded clinical pharmacists led to a significant reduction in clinical inertia. This was a small-scale pilot study, and further research is needed to determine the effect of this intervention on BP reduction.

Intensifying approaches to address clinical inertia among cardiovascular disease risk factors: A narrative review

OBJECTIVE

Clinical inertia, the absence of treatment initiation or intensification for patients not achieving evidence-based therapeutic goals, is a primary contributor to poor clinical outcomes. Effectively combating clinical inertia requires coordinated action on the part of multiple representatives including patients, clinicians, health systems, and the pharmaceutical industry. Despite intervention attempts by these representatives, barriers to overcoming clinical inertia in cardiovascular disease (CVD) risk factor control remain.

METHODS

We conducted a narrative literature review to identify individual-level and multifactorial interventions that have been successful in addressing clinical inertia.

RESULTS

Effective interventions included dynamic forms of patient and clinician education, monitoring of real-time patient data to facilitate shared decision-making, or a combination of these approaches. Based on findings, we describe three possible multi-level approaches to counter clinical inertia - a collaborative approach to clinician training, use of a population health manager, and use of electronic monitoring and reminder devices.

CONCLUSION

To reduce clinical inertia and achieve optimal CVD risk factor control, interventions should consider the role of multiple representatives, be feasible for implementation in healthcare systems, and be flexible for an individual patient's adherence needs.

PRACTICE IMPLICATIONS

Representatives (e.g., patients, clinicians, health systems, and the pharmaceutical industry) could consider approaches to identify and monitor non-adherence to address clinical inertia.

Identifying contributing factors influencing pediatric nurses' and health professionals' self-reported collaborative practice behaviors

PURPOSE

In this study, we examined the influence of interprofessional American Heart Association (AHA) resuscitation courses on pediatric health care professionals' (N = 218) self- reported collaborative practice behaviors (CPBs) and examined differences in CPBs between nursing, medicine, and respiratory therapy.

DESIGN AND METHODS

A mixed methods explanatory design was utilized with a sample of pediatric nurses, nurse practitioners, physicians, and respiratory therapists. Data were collected using the Interprofessional Collaborative Competency Attainment Survey (ICCAS) and two open-ended questions. Data analysis included: exploratory factor analysis, paired t-tests, mixed effects modeling and directed content analysis. Inferences were made across quantitative and qualitative data.

RESULTS

Statistically significant improvement in mean CPB scores was demonstrated by all professions (t (208) = -12.76; ρ < 0.001) immediately after the AHA courses. Qualitative responses indicated physicians identified roles and responsibilities (94%, n = 17) as the most important CPB. Communication was identified by nurses (78%, n = 76), nurse practitioners (100%, n = 11) and respiratory therapists (71%, n = 5) as most important.

CONCLUSIONS

Participation in an interprofessional AHA course significantly increased mean self-reported CPB scores. Changes in mean CPB scores were sustained over 6 weeks upon return to clinical practice.

PRACTICE IMPLICATIONS

Future research focused on CPBs of front-line health care professionals can provide an accurate portrayal of an interprofessional team and can inform how collaborative practice is established in everyday clinical practice.

Time in Target Range for Systolic Blood Pressure and Cardiovascular Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

Background

The association between blood pressure control and clinical outcomes is unclear among patients with heart failure with preserved ejection fraction. Both too high and too low of systolic blood pressure (SBP) have been reported to be related to poor clinical prognosis. This study aimed to assess the association between time in SBP target range and adverse clinical events among patients with heart failure with preserved ejection fraction.

Methods and Results

This study was a secondary analysis of the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trial, a randomized clinical trial that compared the efficacy and safety of spironolactone in patients with heart failure with preserved ejection fraction. Time in target range (TTR) was calculated using linear interpolation, with the target range of SBP defined as 110 to 130 mm Hg. The association between TTR with adverse outcomes was estimated using multivariable Cox regression to adjust for multiple confounders. Participants with greater TTR were younger, more likely to be White, had less comorbidities, and lower body mass index. After adjusting for multiple covariates including mean SBP, 1‐SD increment (38.3%) of TTR was significantly associated with a decreased risk of primary composite end point (hazard ratio [HR], 0.81 [0.73–0.90]), as well as a lower risk of all‐cause mortality (HR, 0.81 [0.73–0.90]), cardiovascular death (HR, 0.78 [0.68–0.90]), and heart failure hospitalization (HR, 0.85 [0.74–0.97]). Results were similar when participants were categorized by TTR groups. Subgroup analyses showed that the associations were more significant in young people than in the old (P_interaction=0.028).

Conclusions

In patients with heart failure with preserved ejection fraction, greater time in SBP target range was statistically associated with a decreased risk of cardiovascular outcomes and mortality events beyond blood pressure level, especially among younger patients.

Impact of an ambulatory care pharmacist on provider relative value units in a rural clinic

Introduction

Collaborative team-based care models have been shown to improve the quality of care provided to patients and may increase productivity along with patient access to care. Productivity is often tracked via work relative value units (wRVU). The primary objective of this project was to evaluate how a collaborative practice model affects tracked productivity.

Methods

Data regarding wRVU were retrospectively extracted from the electronic medical record from a single center. De-identified data points included total number of patients seen and level of service billed for the visit. Visits were grouped as collaborative (physician-pharmacist) or independent (physician alone). Relative value unit totals were calculated separately for individual physicians and pharmacy visits and also combined for collaborative team wRVU totals. Wilcoxon and descriptive statistics were used for analysis. All statistical analyses were performed using SAS v 9.4 (Cary, NC).

Results

A total of 624 patient visits were reviewed. Total number of patients seen by physicians working in collaboration was on average 19.25 per day versus 12.9 per day for those working independently. When evaluating only the average per encounter wRVU for each provider removing collaborative patients, the three providers who worked in the collaborative model averaged 1.45, 1.48, and 1.55 wRVU per patient respectively, compared to those who worked singularly (1.37 and 1.30). This was found to be statistically significant in the unadjusted mixed model (P = 0.0476), but not maintained once adjusted.

Conclusion

Physicians working in collaboration with a pharmacist were able to bill at a higher level on average suggesting more productivity.

Development and implementation of blood pressure screening and referral guidelines for German community pharmacists

Involvement of community pharmacists in the detection and control of hypertension improves patient care. However, current European or North‐American guidelines do not provide specific guidance how to implement collaboration between pharmacists and physicians, especially when and how to refer patients with undetected or uncontrolled hypertension to a physician. The German Society of Cardiology and the ABDA – Federal Union of German Associations of Pharmacists developed and tested referral recommendations for community pharmacists, embedded in two guideline worksheets. The project included a guideline‐directed blood pressure (BP) measurement and recommendations when patients should be referred to their physician. A “red flag” referral within 4 weeks was recommended when SBP was >140 mm Hg or DBP >90 mm Hg (for subjects <80 years), and >160 mm Hg or >90 mm Hg (≥80 years) in undetected individuals, or >130 mm Hg or >80 mm Hg (<65 years) and >140 mm Hg or >80 mm Hg (≥65 years) in treated patients. BP was measured in 187 individuals (86 with known hypertension, mean [±SD] age 62 ± 15 years, 64% female, and 101 without known hypertension, 47 ± 16 years, 75% female) from 17 community pharmacies. In patients with hypertension, poorly controlled BP was detected in 55% (n = 47) and were referred. A total of 16/101 subjects without a history of hypertension were referred to their physician because of uncontrolled BP. Structured BP testing in pharmacies identified a significant number of subjects with undetected/undiagnosed hypertension and patients with poorly controlled BP. Community pharmacists could play a significant role in collaboration with physicians to improve the management of hypertension.

Perspectives of primary care physicians and pharmacists on interprofessional collaboration in Kuwait: A quantitative study

Collaborative practice between physicians and pharmacists has a positive effect on healthcare outcomes. Understanding the local data related to this collaboration is vital in establishing efficient collaboration. Therefore, this study was designed to assess the collaborative relationships between physicians and pharmacists working in the primary healthcare centres regarding their attitudes and experiences, preferred methods of communication, perceptions related to the role of pharmacists, areas of potential further collaboration, and perceived barriers. A cross-sectional study was conducted using two parallel pretested self-administered questionnaires on a sample of 518 randomly selected physicians and pharmacists. Descriptive and comparative analyses were used in data analysis. The overall response rate was 86.3%. Although over 98% of respondents agreed that physician-pharmacist collaboration improves patient outcomes, more than half of the physicians (52.1%) and pharmacists (55.7%) had never practised collaboratively. Both groups preferred to communicate face-to-face (76.7%) or via telephone (76.5%). Both professions showed good agreement on pharmacists' roles related to managing side effects, improving adherence, assisting in dosage adjustment, providing advice regarding drug interactions, and providing drug information to physicians. They indicated disagreements on the importance of dispensing of prescriptions and providing advice to physicians regarding modification of drug therapy. Both groups expressed overall positive perceptions of the potential for further collaboration in areas related to the clinical roles of pharmacists, which were significantly higher among those with practice experience of < 10 years and those aged < 40 years (p<0.05). The top four perceived barriers to collaborative practice were lack of time (84.1%), lack of financial compensation (76.3%), lack of face-to-face communication (68.9%), and the possible fragmentation of patient care by the involvement of multiple healthcare professionals (68.9%). The present findings provide valuable input that could be a catalyst to enhance or establish physician-pharmacist collaboration in primary healthcare settings in Kuwait.

Knowledge of heart attack and stroke symptoms among US Native American Adults: a cross-sectional population-based study analyzing a multi-year BRFSS database

Background

Heart disease and stroke are among the leading causes of death in Native Americans. Knowledge of heart attack and stroke symptomology are essential for prompt identification of symptoms and for appropriate action in seeking care. Knowledge of heart attack and stroke symptoms among US Native American adults was this study’s focus.

Methods

Multivariate techniques were used to analyze national surveillance data. Native American adults comprised the study population. Low heart attack and stroke knowledge score was the dependent variable.

Results

Logistic regression analysis yielded that Native American adults with low heart attack and stroke composite knowledge scores were more likely to be: older, less educated, poorer, uninsured, a rural resident, male, without a primary health care provider, and lacking a recent medical checkup.

Conclusions

The identified characteristics of Native American adults with heart attack and stroke knowledge deficits or disparities should guide educational initiatives by health care providers focusing on improving such knowledge.

The role of the pharmacist in hypertension management

PURPOSE OF REVIEW

Hypertension remains a vital, modifiable risk factor in the prevention of cardiovascular disease. However, many patients do not achieve their therapeutic goals for numerous reasons which can include poor disease insight and nonadherence. Pharmacists can be key players in controlling hypertension, given their medication knowledge and patient counseling skills, yet they remain an underutilized resource in the management of chronic disease states. Various models exist that allow pharmacists to provide direct patient-centered care but practices differ from state to state since pharmacists are not recognized nationally as healthcare providers. This article aims to provide an update on the proven methods in which pharmacists contribute to the management of hypertensive patients.

RECENT FINDINGS

Several recently published studies demonstrate the positive impact of pharmacist intervention and care on patient outcomes in ambulatory and community settings. These practice models include medication therapy management, collaborative drug therapy management, telehealth and team-based care.

SUMMARY

The role of the pharmacist in hypertension encompasses medication management, disease state education and patient counseling and is most successful when integrated into the patient's care team. Further validation through larger, prospective trials and evaluation of long-term outcomes, such as mortality, remain viable research opportunities.

The state of the science of interprofessional collaborative practice: A scoping review of the patient health-related outcomes based literature published between 2010 and 2018

Introduction

If interprofessional collaborative practice is to be an important component of healthcare reform, then an evidentiary base connecting interprofessional education to interprofessional practice with significantly improved health and healthcare outcomes is an unconditional necessity. This study is a scoping review of the current peer reviewed literature linking interprofessional collaborative care and interprofessional collaborative practice to clearly identified healthcare and/or patient health-related outcomes. The research question for this review was: What does the evidence from the past decade reveal about the impact of Interprofessional collaborative practice on patient-related outcomes in the US healthcare system?

Materials and methods

A modified preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach was followed.

Results

Of an initial 375 articles retrieved 20 met review criteria. The most common professions represented in the studies reviewed were physicians, pharmacists and nurses. Primary care was the most common care delivery setting and measures related to chronic disease the most commonly measured outcomes. No study identified negative impacts of interprofessional collaborative practice. Eight outcome categories emerged from a content analysis of the findings of the reviewed studies.

Conclusions

The results suggest a need for more research on the measurable impact of interprofessional collaborative practice and/or care on patient health-related outcomes to further document its benefits and to explore the models, systems and nature of collaborations that best improve population health, increase patient satisfaction, and reduce cost of care.

Key components of success in a randomized trial of blood pressure telemonitoring with medication therapy management pharmacists

OBJECTIVES

The Hyperlink trial tested a 12-month intervention of home blood pressure (BP) telemonitoring with pharmacist case management in adults with uncontrolled hypertension. The intervention resulted in improved BP control compared with usual care at both 6 (72% vs. 45%; P < 0.001) and 12 months (71% vs. 53%; P = 0.005). We sought to investigate factors contributing to intervention success.

DESIGN

Mixed-methods analysis of process of care data, patient focus groups, and pharmacist interviews.

PARTICIPANTS

Data from 228 intervention patients were examined from the original 450 patients randomly assigned from 16 primary care clinics. Five patient focus groups and 4 pharmacist interviews were conducted to ascertain the patient and pharmacist perspective. Focus group and interview data were coded, and themes relevant to pharmacists were identified.

OUTCOME MEASURES

Home BP readings of less than 135/85 mm Hg and patient focus group and pharmacist interview themes.

RESULTS

Mean BP at the intake visit was 148/85 mm Hg. Antihypertensive medications were adjusted in 10% of patients at the initial in-person visit, 33% at phone visit 1, 36% at phone visit 2, and 19% at phone visit 3. Thereafter, medication changes declined. The mean home BP for patients at the first phone visit was 136/80 mm Hg, 126/74 mm Hg at 3 months, and 123/73 mm Hg at 5 months, with little change thereafter. Key components of success from patient and pharmacist interviews included a strong patient-pharmacist relationship, individualized treatment plans, and frequent phone contact with the pharmacist.

CONCLUSION

Frequent adjustments to the antihypertensive treatment regimen based on home BP telemonitoring resulted in rapid lowering of BP. Our results suggest that an intensive telephone-based intervention with the key components of medication adjustments, a strong patient and pharmacist relationship, and individualized treatment plans can achieve BP control in only 3 months in many patients with uncontrolled hypertension.