Cardiovascular Risk Reduction and the Community Pharmacist∗

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

VOL. 67, NO. 24, 2016

ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 0735-1097/$36.00

PUBLISHED BY ELSEVIER

http://dx.doi.org/10.1016/j.jacc.2016.04.018

EDITORIAL COMMENT

Cardiovascular Risk Reduction and the Community Pharmacist* Larry A. Weinrauch, MD,a Alissa R. Segal, PHARMD,a,b John A. D’Elia, MDa

H

istorically, partnerships among patient,

patients at 56 Canadian pharmacy clinics randomized

pharmacist,

suffi-

to usual pharmacy care or an intervention by

ciently close that substantive discussion

participating pharmacists focused on directing more

could generate quick and beneficial solutions. Over

intensive goal-directed therapy to reduce cardiovas-

the past 4 decades, scientific advancement has led

cular risk. The case-finding recruitment strategies

to increasing survival with decreased morbidity for

required presence of peripheral, cardiac, or cerebro-

several chronic illnesses. The ubiquitous patient

vascular disease, an estimated Framingham risk score

with diabetes, chronic systolic heart failure, and atrial

>20%, and at least 1 of the following: blood pressure

fibrillation in the 1970s would have received a sulfo-

(BP) >140/90 or >130/80 mm Hg if diabetic, low-

nylurea, digoxin, warfarin, and a diuretic. Today

density lipoprotein cholesterol (LDL-C) >2.0 mmol/l

that patient might be taking 2 or more antidiabetic

(77 mg/dl), glycosylated hemoglobin (HbA1c) >7.0%,

agents, a statin, angiotensin-converting enzyme

or current smoker. This is an enriched population for

inhibitor/angiotensin receptor blocker/angiotensin

cardiovascular risk.

and

physician

were

receptor-neprilysin inhibitor, beta-blocker, spirono-

The authors hypothesized that pharmacist inter-

lactone, diuretics, either aspirin plus a new oral anti-

vention (compared with usual care) would reduce

coagulant or warfarin, and perhaps digoxin. Such

cardiovascular risk score, LDL-C, HbA 1c, systolic and

polypharmacy, although backed by scientific evi-

diastolic BPs, and smoking at the end of a 3-month

dence for patients at highest risk, is a substrate for

trial. The intervention was relatively simple: phar-

drug-drug interactions, patient nonadherence, and

macists

management confusion.

while advancing medications and altering diet when

communicated

with

treating

physicians

However, as pharmacies and insurers consolidate,

appropriate. Indeed, they did demonstrate improve-

the community is losing to wholesale economic con-

ment in these surrogate outcomes. The patients with

siderations one of its most effective proponents for

diabetes dropped their baseline HbA1c of 8.6% to

health care delivery and greatest partners with

7.6%, with 42% achieving an HbA1c of <7.0%, signif-

physicians in health care.

icantly better than the usual care group. This was

SEE PAGE 2846

accomplished in a very short period of time with monthly pharmacy visits.

In this issue of the Journal, Tsuyuki et al. (1) of the

That better management could be achieved with

RxEACH (Alberta Vascular Risk Reduction Commu-

appropriate case finding and rigorous attention to

nity Pharmacy Project) report the results of 723

goals should be a wake-up call. Whether such management must be delivered by physicians, pharma-

*Editorials published in the Journal of the American College of Cardiology

cists, nurse practitioners, or other facilitators (such as

reflect the views of the authors and do not necessarily represent the

paramedics in Boston or specialized multilingual

views of JACC or the American College of Cardiology.

clinical trainees in India) (2,3) is less important than

From the aKidney and Hypertension Section, Joslin Diabetes Center,

the observation that we are able to recruit or case find

Harvard Medical School, Boston, Massachusetts; and the bDepartment of Pharmacy Practice, MCPHS University, Boston, Massachusetts. Dr. Segal has served on the advisory board for Lilly USA, LLC. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

patients who might benefit from additional management and that better results are rapidly achievable. The burden of medical therapy for hypertensive patients with diabetes looms large, especially for

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Weinrauch et al.

JACC VOL. 67, NO. 24, 2016 JUNE 21, 2016:2855–7

CV Risk Reduction and the Pharmacist

those with renal disease (4–7). Removing financial

Social Security Act, thus limiting program imple-

disincentives to adherence has not been demonstrated

mentation and preventing widespread compensation

to improve outcomes for patients after myocardial

for services provided in collaborative care programs.

infarction (8). Even among heart failure patients

Individual states establish provider status or expand

requiring

to

scope of practice in numerous ways; thus, applica-

guidelines remains suboptimal (9). Adverse morbidity

bility of these observations may vary by geography.

implanted

defibrillators,

adherence

and mortality have been linked to nonadherence to

This study suggested at least short-term benefits for

guideline-directed therapy (10,11). The RxEACH study

integrating community pharmacists into a collabora-

results demonstrated room for improvement of med-

tive care initiative, but for most patients to benefit

ical care in the trial population (1), hardly surprising

from more extensive risk reduction, pharmacists

given how many people are not currently achieving

would need to be designated “providers” by federal

guideline targets for lipids, BP, smoking cessation, or

regulations.

glycemic management. Observations from this study

The average high-risk patient encounters the

should trigger analysis of potential public health

physician far less often than the pharmacist. In our

benefits from additional studies of larger size and

aging population, the patients at risk for drug-drug

longer duration, if for no other reason than financial

interaction, medication confusion, or nonadherence

benefits to the community.

may also be limited by visual or other handicaps, such

Although there is no reason to believe cooperative

as hearing deficits or inability to open containers.

efforts would not be durable, longer studies will be

The loss of the community pharmacist may remove

required to delineate cost and risk, and assess follow-

measures of safety and coaching from these patients.

up. This study had other limitations; there was no

Physicians often use “lack of training” as an excuse

documentation of care leading up to study partici-

to prevent expansion of the pharmacist’s scope of

pation (no run-in), and body mass index (BMI) was

practice, but pharmacy school curricula and stan-

not followed throughout. While therapeutic inertia

dards for accreditation have evolved into compre-

is occasionally blamed for failure to achieve goals,

hensive medication management and collaborative

it cannot be invoked if the patient is not under

care in all health care settings (12). Although design of

active care. Additionally, data regarding potential

these programs may vary significantly, each empha-

therapeutic missteps are not available. To achieve

sizes the patient-centered care process with essential

such rapid reductions in glycemia, one must risk

components of collaboration, communication, and

hypoglycemia; for hypertension therapy, one risks

documentation (13). However, cost of pharmacist care

hypotension.

cannot be balanced by revenue through traditional

Another major limitation: investigators may have

reimbursement. Some institutional programs have

recruited a patient cohort that has escaped careful

promoted pharmacist services as cost-containment

follow-up. This will need to be addressed in future

measures, integrating them into patient-centered

studies. It would also be important to know in more

medical homes and recovering costs by preventing

detail

drug-drug

the

interventions,

including

medications

interactions

and

errors,

and

acting

used, and the extent of hypoglycemia or other drug

synergistically with clinicians to decrease adverse

treatment-related problems. Improvement in BP,

outcomes.

lipids, and glycemia may certainly be related to weight

This study highlighted use of a provincial remu-

loss. A successful weight management or bariatric

neration program by community pharmacists to

surgical program targeting obese 60-year-olds (BMI

determine whether cardiovascular risks could be

in this study was >33 kg/m 2) would be anticipated

lowered in a relatively homogeneous population. The

to replicate these findings (albeit with higher costs

extent to which such studies apply to areas with

and risks). No medication dosages are available in

multiple languages is unclear. Long-term evaluation

the current presentation, meaning some therapeutic

and outcome trials regarding collaboration with

changes may be undetected yet responsible for a

community pharmacists incorporating various reim-

major portion of the findings. Notwithstanding, the

bursement models may provide additional evidence

investigators were able to recruit a high-risk group

as to whether pharmacy services should be included

and improve care facilitated by pharmacists.

within the Social Security Act.

Limited information was provided on remunera-

Another important issue to consider in expanding

tion or other barriers to the intervention. The authors

this model: currently, there appears to be no standard

noted compensation for pharmacist care was covered

process by which information available to the physi-

under a program available in Alberta; in the United

cian is fed back to the pharmacist. Not knowing who

States, pharmacists are excluded as providers in the

is responsible for disseminating the information and

Weinrauch et al.

JACC VOL. 67, NO. 24, 2016 JUNE 21, 2016:2855–7

how

patient

privacy

CV Risk Reduction and the Pharmacist

will

be

protected

during

such communications may be major implementation

REPRINT REQUESTS AND CORRESPONDENCE: Dr.

limitations.

Larry A. Weinrauch, Harvard Medical School, 521

As with many important observations, more ques-

Mount

Auburn

Street,

Suite

204,

Watertown,

tions must be answered and studies done to relate

Massachusetts 02472-4153. E-mail: lweinrauch@hms.

short-term benefits to long-term outcomes.

harvard.edu.

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Coll Cardiol 2016;67:1516–8. 12. Accreditation Council for Pharmacy Education.

7. Weinrauch LA, Bayliss G, Segal AR, et al. Renal function alters antihypertensive regimens in type 2 diabetic patients. J Clin Hypertens (Greenwich) 2016 Mar 2 [E-pub ahead of print].

Accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree, “Standards 2016”. Available at: https://www.acpe-accredit. org/standards/. Accessed April 3, 2016.

8. Choudhry NK, Avorn J, Glynn RJ, et al. Full coverage for preventive medications after myocardial infarction. N Engl J Med 2011;365:2088–97.

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KEY WORDS adherence, community pharmacy, diabetes, hypertension control, risk factors

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