ACEI angiotensin-converting enzyme inhibitor ARB angiotensin receptor blocker BP blood pressure CCB calcium channel blocker CKD chronic kidney disease CVD cardiovascular disease ESRD end-stage renal disease GFR glomerular filtration rate HF heart failure

Background Studies have demonstrated that blood pressure (BP) control can be improved when clinical pharmacists assist with patient management. The purpose of this study was to evaluate the effectiveness of a physician/pharmacist intervention to improve BP control. Methods This was a prospective, cluster-randomized controlled clinical trial with clinics randomized to control (n=3) or intervention (n=3) groups. The study enrolled 402 patients with uncontrolled hypertension (mean age 58.3 years). Clinical pharmacists made drug-therapy recommendations to physicians based on national guidelines. Research nurses performed BP measurements and 24-hour BP monitoring. Results Guideline adherence scores increased from 49.4 ± 19.3 at baseline to 53.4 ± 18.1 at 6 months (9% increase) in the control group and from 40.4 ± 22.6 to 62.8 ± 13.5 (57% increase) in the intervention group (p=0.089 adjusted comparison between groups). Mean BP decreased 6.8/4.5 and 20.7/9.7 mm Hg in the control and intervention groups, respectively, (p<0.05 for between-group systolic BP (SBP) comparison). The adjusted difference in SBP was −12.0 (95% CI: −24.0, 0.0) mm Hg, while the difference in diastolic BP (DBP) was −1.8 (CI: −11.9, 8.3). The 24-hour BP levels showed similar effect sizes. BP was controlled in 29.9% of patients in the control group and 63.9% in the intervention group (adjusted odds ratio 3.2; CI: 2.0, 5.1; p<0.001). Conclusions A physician/pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates when compared to a control group. Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management.

Background One strategy that has had the greatest effect on improving blood pressure (BP) includes team-based care. The purpose of this systematic review was to determine the potency of interventions for BP involving nurses or pharmacists. Methods A Medline search for controlled clinical trials that involved a nurse or pharmacist intervention was conducted. Mean reductions in systolic (S) and diastolic (D) BP were determined by two reviewers who independently abstracted data and classified the different intervention components. Results Thirty-seven papers met the inclusion criteria. Education on BP medications was significantly associated with improved BP (−8.75/−3.60 mm Hg). Other strategies that had large effect sizes on SBP included: pharmacist made treatment recommendation (−9.30 mm Hg), nurse did the intervention (−4.80 mm Hg), and a treatment algorithm was used (−4.00 mm Hg). The odds ratio (OR) and 95% confidence interval (CI) for controlled BP were: nurses OR=1.69 (CI = 1.48, 1.93), pharmacists within primary care clinics OR=2.17 (CI = 1.75, 2.68) and community pharmacists OR=2.89 (CI = 1.83, 4.55), Mean reductions in SBP were: nursing studies = 5.84 ± 8.05 mm Hg, pharmacists in clinics = 7.76 ± 7.81 mm Hg and community pharmacists = 9.31 ± 5.00 mm Hg but there was no significant differences between the nursing and pharmacy studies (p≥0.19). Conclusion Team-based care was associated with improved BP control and individual components of the intervention appeared to predict potency. Implementation of new hypertension guidelines should consider changes in the health-care organizational structure to include important components of team-based care.

Background The purpose of this study was to evaluate if a physician/pharmacist collaborative model would be implemented as determined by improved blood pressure (BP) control in primary care medical offices with diverse geographic and patient characteristics and whether long-term BP control could be sustained. Methods and Results Prospective, cluster-randomized trial of 32 primary care offices stratified and randomized to: control, 9-month intervention (brief), 24-month intervention (sustained). We enrolled 625 subjects with uncontrolled hypertension; 54% from racial/ethnic minority groups, and 50% with diabetes or chronic kidney disease (CKD). The primary outcome of BP control at 9 months was 43% in intervention offices (n=401) compared to 34% in the control group (n=224) (adjusted odds ratio [OR] 1.57 [95% CI 0.99–2.50], p = 0.059). The adjusted difference in mean systolic/diastolic BP between the intervention and control groups for all subjects at 9 months was −6.1/−2.9 mm Hg (p =0.002 and p=0.005, respectively), and it was −6.4/−2.9 mm Hg (p=0.009 and p=0.044, respectively) in subjects from racial or ethnic minorities. BP control and mean BP were significantly improved in subjects from racial minorities in intervention offices at 18 and 24 months (p=0.048 to p<0.001) compared to the control group. Conclusions While the results of the primary outcome (BP control) were negative, the key secondary endpoint (mean BP) was significantly improved in the intervention group. Thus, the findings for secondary endpoints suggest that team-based care utilizing clinical pharmacists was implemented in diverse primary care offices and BP was reduced in subjects from racial minority groups. Clinical Trial Registration Information NCT00935077: http://clinicaltrials.gov/ct2/show/NCT00935077

BackgroundPharmacists may improve medication-related outcomes during transitions of care. The aim of the Iowa Continuity of Care Study was to determine if a pharmacist case manager (PCM) providing a faxed discharge medication care plan from a tertiary care institution to primary care could improve medication appropriateness and reduce adverse events, rehospitalization and emergency department visits.MethodsDesign. Randomized, controlled trial of 945 participants assigned to enhanced, minimal and usual care groups conducted 2007 to 2012. Subjects. Participants with cardiovascular-related conditions and/or asthma or chronic obstructive pulmonary disease were recruited from the University of Iowa Hospital and Clinics following admission to general medicine, family medicine, cardiology or orthopedics. Intervention. The minimal group received admission history, medication reconciliation, patient education, discharge medication list and medication recommendations to inpatient team. The enhanced group also received a faxed medication care plan to their community physician and pharmacy and telephone call 3–5 days post-discharge. Participants were followed for 90 days post-discharge. Main Outcomes and Measures. Medication appropriateness index (MAI), adverse events, adverse drug events and post-discharge healthcare utilization were compared by study group using linear and logistic regression, as models accommodating random effects due to pharmacists indicated little clustering.ResultsStudy groups were similar at baseline and the intervention fidelity was high. There were no statistically significant differences by study group in medication appropriateness, adverse events or adverse drug events at discharge, 30-day and 90-day post-discharge. The average MAI per medication as 0.53 at discharge and increased to 0.75 at 90 days, and this was true across all study groups. Post-discharge, about 16% of all participants experienced an adverse event, and this did not differ by study group (p > 0.05). Almost one-third of all participants had any type of healthcare utilization within 30 days post-discharge, where 15% of all participants had a 30-day readmission. Healthcare utilization post-discharge was not statistically significant different at 30 or 90 days by study group.ConclusionThe pharmacist case manager did not affect medication use outcomes post-discharge perhaps because quality of care measures were high in all study groups.Trial registrationClinicaltrials.gov registration: NCT00513903, August 7, 2007.

Objectives: Patient self-care behaviors, including taking medication, following a meal plan, exercising regularly, and testing blood glucose, influence diabetes control. The purpose of this research was to identify (1) which barriers to diabetes management are associated with problem behaviors and (2) which patient behaviors and barriers are associated with diabetes control.Methods: This was a cross-sectional study of linked medical record and self-reported information from patients with type 2 diabetes. A randomly selected sample of 800 clinic patients was mailed an investigator-developed survey. The study sample consisted of 253 (55%) individuals who had measured glycosylated hemoglobin (HbA1c) within 3 months of the survey date.Results: The barriers to each diabetes self-care behavior differed. Cost was the most common barrier to the 4 self-care behaviors. In a multivariable regression model, the belief that type 2 diabetes is a serious problem and depression were strongly associated with higher HbA1c levels. Lower HbA1c levels were significantly associated with being married and greater self-reported adherence-satisfaction with taking medication and testing blood glucose.Conclusion: This study expanded earlier research by focusing on 4 specific self-care behaviors, their barriers, and their association with HbA1c. Barriers that were significantly associated with HbA1c were specific to the behavior and varied across behaviors. Although the importance of glycemic control is well established, 1 it is often not achieved. 2 Factors contributing to poor control include inadequacies in patient self-care behaviors, medical management, or both. [3][4][5][6][7] Physicians know that patient self-care behaviors influence diabetes control but may lack training for and interest in motivating their patients to improve these behaviors. 8 Contributing to poor control is a paucity of information available about the frequency of problem behaviors, barriers to appropriate care behaviors, or the relationship of specific patient self-care behaviors to glycemic control. 9,10 Our conceptual model for this study is shown in Figure 1, adapted from the works of Glasgow. 11Factors that influence diabetes adherence in our model include personal factors, such as type and duration of diabetes, illness, and other health conditions and psychosocial factors. Glasgow's model places primary emphasis on the variables of the patient-health care provider interactions, compliance, and outcomes. The patient-provider interactions are composed of the patient's perspective and participation, appropriateness of prescriptions, and clarity and specificity of recommendations. The social/environmental influences included barriers to adherence, community resources, social support, and economic factors. The primary emphases of this study were the performance of 4 primary self-care behaviors and specific barriers to these behaviors: (1) medication use, (2) meal plans, (3) exercise, and (4) home glucose testing. In addition, our model attempts to include many ...

Abstract-Adherence to practice guidelines is frequently used as a measure of quality of care. Numerous studies have evaluated physician adherence to hypertension guidelines by prescription data, physician survey data, or medical record review. However, most have methodological limitations that might underestimate physician adherence. Accurate and meaningful characterization of adherence rests on evaluation of varied components of hypertension care, use of explicit validated performance measures, incorporation of implicit and explicit review, and linkage of process measures to blood pressure outcomes. Key Words: hypertension, detection and control Ⅲ population Ⅲ lifestyle Ⅲ epidemiology P ractice guidelines serve as useful tools for clinical decision making. Guidelines are used to reduce practice variation, guide appropriateness, and measure quality of care. 1,2 Ultimately, the goal of a guideline is to improve patient outcomes through a change to evidence-based physician practices. Unfortunately, substantial gaps have been documented between the development and dissemination of consensus statements and their implementation in practice. In short, clinical practice guidelines do not consistently change physician behavior. [3][4][5][6][7] Although the National Heart, Lung, and Blood Institute (NHLBI) has published 7 guidelines for the treatment of hypertension, 8 -14 control of high blood pressure remains suboptimal. An estimated 40% of the 50 million persons in the United States with hypertension remain untreated, and 66% of hypertensive patients have blood pressure values that are not controlled to the recommended levels. 14,15 Many studies have concluded that physician adherence to hypertension guidelines has been low. 16 -22 It is tempting, therefore, to connect poor blood pressure control to poor adherence to hypertension guidelines.However, valid and meaningful conclusions regarding physician adherence and its link to blood pressure control rest on the completion of 2 tasks. First, physician adherence to hypertension guidelines must be assessed accurately. Second, the relation between physician adherence and blood pressure control must be empirically demonstrated.This article reviews pertinent literature regarding physician adherence to hypertension guidelines and the relation of adherence to blood pressure outcomes. The review focuses on methods that limit evaluation of adherence and concludes with recommendations for strengthening future adherence research. Literature SearchA literature search using MEDLINE from 1966 to 2004 was conducted by combining the terms "guideline adherence" and "hypertension." English articles were screened for inclusion by review of the title and abstract. A copy of all studies that compared prescribing trends or physician practice to guideline recommendations was obtained. Bibliographies of chosen references were reviewed for additional citations. Articles that compared physician practice to recommendations of the Joint National Committee (JNC) on the Detection, Evaluation, and ...

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