- Email: [email protected]
Identifying At-Risk Patients Through Community Pharmacy-Based Hypertension and Stroke Prevention Screening Projects
EXPERIENCE
Identifying At-Risk Patients Through Community PharmacyBased Hypertension and Stroke Prevention Screening Projects Stacy A. Mangum, Kim R. Kraenow, and Warren A. Narducci
Objective: To demonstrate whether a community pharmacist can be successful in identifying and referring patients with elevated blood pressure and/or increased risk of stroke. Setting: An independent community pharmacy and well-elderly housing facility in rural Iowa. Practice Description: The pharmacy had dedicated space for patient care activities, had a community pharmacy practice resident, and served as a clerkship site for a local school of pharmacy. One of three well-elderly housing facilities in the same community was used as a screening site for the stroke prevention program. Practice Innovation: All adults entering the pharmacy during the time the blood pressure project was underway were offered a free blood pressure screening. If readings were elevated, patients were referred to their primary care provider. For stroke prevention, a screening using the American Heart Association stroke risk assessment protocol was held at the pharmacy and the well-elderly housing facility. Main Outcome Measures: Blood pressure categories and stroke risk (normal, mild, moderate, and high) categories obtained during the screening. Results: A total of 351 patients were screened for hypertension. Of these, 216 (62%) had readings greater than 140/90 mm Hg. Of the 121 patients referred to their physician, 43 (36%) had a regimen change. A total of 50 patients were screened for stroke risk. Results of the risk assessments for patients screened were normal, 4%; mild, 26%; moderate, 32%; high, 38%. Conclusion: These projects demonstrated that, through ongoing screening programs, community pharmacists are in an ideal position to screen patients at risk for cardiovascular and cerebrovascular disease and refer patients to their physicians for further evaluation.
Keywords: Stroke, hypertension, community pharmacy, ambulatory care, patient education, counseling, screening. J Am Pharm Assoc. 2003;43:50–5.
Hypertension is a major risk factor for cardiovascular morbidity and mortality from coronary artery disease (including ischemic heart disease, myocardial infarction, and sudden death), cardiac disease (left ventricular hypertrophy and congestive heart failure), renal failure, and blindness. Hypertension also greatly increases the risk for developing cerebrovascular disease. At least 50 million people in the United States have elevated blood pressure, and, according to the Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI), the rates of awareness, treatment, and control of hyperReceived March 4, 2002, and in revised form May 29, 2002. Accepted for publication August 21, 2002. Stacy A. Mangum, PharmD, is clinical assistant professor; Kim R. Kraenow, PharmD, is clinical assistant professor, School of Pharmacy, University of Missouri–Kansas City. Warren A. Narducci, PharmD, is owner and pharmacist in charge, Nishna Valley Pharmacy, Shenandoah, Iowa. Correspondence: Stacy A. Mangum, PharmD, School of Pharmacy, University of Missouri–Kansas City, M3-C19 Medical School, 2411 Holmes Street, Kansas City, MO 64108-2792. Fax: 816-753-0804. E-mail: [email protected].
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tension have declined slightly in recent years.1 Stroke is the leading cause of disability and the third leading killer in America. In 1999 strokes killed 167,366 people, accounting for about 1 of every 14.3 deaths.2 The American Heart Association (AHA) has identified several factors that influence the risk of stroke, including increasing age, male sex, heredity, race, prior stroke, high blood pressure, cigarette smoking, diabetes mellitus, carotid artery disease, heart disease, transient ischemic attacks, high red blood cell count, and sickle cell anemia.3 JNC VI suggests that community screening for high blood pressure is an important strategy for primary prevention of hypertension.1,4 Screening programs are also vital for monitoring progress and promoting adherence to therapy for high blood pressure and identifying patients at increased risk for stroke. Community pharmacists are in a strong position to identify patients at risk for cardiovascular and cerebrovascular disease through simple hypertension and stroke screening programs. The potential benefit of screening is supported by a 1999 study conducted by researchers at the University of Minnesota and Ohio State University in which community pharmacists reported an average of 59 face-to-face interactions with individuals daily.5 In
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fact, positive clinical, economic, and humanistic outcomes have been demonstrated in hypertensive patients receiving comprehensive pharmaceutical care in community pharmacies.6–10 Despite these demonstrated benefits, relatively few community pharmacists regularly screen their patients for hypertension or other risk factors for cerebrovascular disease. This may be due to the assumption that formal programs such as those described in the previously cited studies are too difficult or time-consuming for the average community pharmacist. In this article we describe two screening projects conducted at Travis Pharmacy (now Nishna Valley Pharmacy), an independent community pharmacy in Shenandoah, Iowa, (pop. approximately 6,000) that serves as a community pharmacy residency and clerkship site for the University of Nebraska Medical Center College of Pharmacy. We hope that by sharing the results of our screening projects we will encourage other community pharmacists to implement similar services.
Hypertension Project O bjective The objective of the hypertension screening project was to demonstrate whether a community pharmacist can be successful in identifying and referring patients with elevated blood pressure. Practice Innovation Adults who entered the pharmacy between July 15, 1996, and February 11, 1997, were offered a free blood pressure screening. Systolic and diastolic blood pressures were measured by a pharmacist or pharmacy student using the Dynapulse 200M computerized cardiovascular monitoring system (Pulse Metric, Inc., San Diego, Calif.). Patients rested in a chair for 5 minutes before their blood pressure was measured. During this time, the pharmacist or pharmacy student collected patient data, including date of birth, current medication use, diagnosis, primary care provider’s name, normal blood pressure if known, and any lifestyle factors that can affect blood pressure (e.g., caffeine intake, food ingestion, exercise, smoking, etc.). In addition, patients taking antihypertensive medications were asked to estimate how often they missed a dose of that medication. Compliance counseling was then provided to determine the cause of noncompliance and to suggest possible solutions to the problem. When a blood pressure reading was elevated, the pharmacist or pharmacy student waited at least 2 minutes and then took the reading again. If the reading was still elevated, the patient’s blood pressure was taken manually (using a stethoscope and sphygmomanometer) by the community pharmacy practice resident, who was the project coordinator. All blood pressure readings were originally stratified according to JNC V11 classifications and subsequently reclassified using the revised JNC VI categories (see Table 1). All patients with blood pressures indicating stage 1
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hypertension or higher were counseled regarding recommended course of action on the basis of the JNC V treatment guidelines.11 So as not to overwhelm local physicians with referrals, patients previously diagnosed with hypertension who reported being followed by their physician were only referred if their blood pressure reading at the screening was higher than their usual readings or indicated stage 2 hypertension or higher. Patients not previously diagnosed as hypertensive, but with stage 1 or higher blood pressure readings, were also referred. Each patient who was referred was given a written description of the intervention to give their physician (see Appendix 1). Any patients with stage 2 or higher readings were referred to their physician. To make this referral, the pharmacist called the physician, while the patient waited, to determine when the physician could see the patient. In addition, a follow-up intervention form describing the blood pressure reading at the pharmacy and the date of referral was sent to the physician. Referred patients were advised to follow up with the pharmacist after they had seen their physician. Upon his or her return to the pharmacy, the patient’s blood pressure was again taken and recorded in his or her chart. Compliance counseling similar to that given on the first visit was conducted at each visit to encourage adherence to the prescribed regimen.
Results A total of 351 patients were screened. Of these, 181 (52%) patients had an existing diagnosis of primary hypertension, 5 (1%) had secondary hypertension, 103 (29%) had not received a previous diagnosis (i.e., were unaware of their blood pressures), and 62 (18%) were unsure about their diagnosis (see Table 2). The average age of the patients was 63 years (range, 19 to 94). Because of community population demographics, all except two of the people screened (both Hispanic) were white. Forty percent of the participants were men and 60% were women. The number of follow-up visits to the pharmacy made by each patient ranged from two to four. One hundred twenty-one patients (34%) were referred to their physician. Forty-three (36%) had a regimen change as a result of this referral, as determined by patient interview and review of dispensing records (see Table 3). Of the Table 1. Classification of Blood Pressure for Adults Age 18 and Older Category
Systolic (mm Hg)
Optimal
< 120
and
< 80
Normal
< 130
and
< 85
130– 139
or
85– 89
Stage 1
140– 159
or
90– 99
Stage 2
160– 179
or
100– 109
High-normal
Diastolic (mm Hg)
Hypertension
Stage 3
180
or
110
Source: Reference 1.
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Table 2. Hypertension Stage by Existing Diagnosis: Blood Pressure Reading at First Screening
Existing Diagnosis at Screening Primary hypertension Secondary hypertension Unaware/unknown
JNC VI Stage Classification (No.)1 1 2 3
Normal No.
High–Normal No.
Total No.
25
27
79
37
13
0
0
4
1
0
5
47
36
63
15
4
165
181
JNC VI = Sixth Report of the Joint National Committee on Detection, Evaluation, and Teatment of High Blood Pressure.
103 subjects who did not have a preexisting diagnosis of hypertension, 47 (46%) were referred to their physician, and 6 (6%) were subsequently diagnosed as hypertensive and started on antihypertensive therapy. At their first screening, 184 patients (52% of those screened) were taking at least one antihypertensive medication. Of these, 129 (70%) had readings indicating stage 1 hypertension or higher at the first screening.
Stroke Prevention Project O bjective The objective of this project was to demonstrate whether a community pharmacist can be successful in identifying and referring patients with increased risk of stroke based on AHA’s screening and stroke risk assessment protocol. Practice Innovation A 1-day stroke prevention screening using AHA’s stroke risk assessment protocol provided by the AHA Iowa affiliate was held at Travis Pharmacy and a well-elderly housing facility. The screening was advertised during a “Talk With Your Pharmacist” radio segment and by posting flyers at both screening locations. Patients who volunteered to participate were asked to sign a liability waiver and a release of information form. Screenings were completed by pharmacists with expertise in blood pressure assessment and a physician assistant who was skilled in physical diagnosis and electrocardiography. The AHA Iowa affiliate provided information and written materials on risks associated with stroke. A brief medical history was obtained to determine an individual’s risk for stroke. Data obtained included sex, age, diagnosis of diabetes, cardiovascular and/or cerebrovascular disease, blood pressure medication use, and history of cigarette smoking. Based on AHA’s risk assessment protocol, point values were assigned for specific risk factors, and the total score on the Stroke Risk Profile was used to stratify patients into normal, mild, moderate, and high risk groups (see Appendix 2). A physical examination consisting of blood pressure, pulse, and carotid bruit evaluation was completed on each patient. When an irregular pulse was detected, a standard three-lead electrocardiogram
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(ECG) was performed. Points were given for systolic blood pressure measurements and based on ECG results, including atrial fibrillation or left ventricular hypertrophy on the basis of AHA criteria. After calculating an individual’s score, pharmacists explained the risk for stroke to the patient and discussed ways to reduce risk and identify warning signs for stroke. Letters were sent to physicians informing them of patients who had stage 1, 2, or 3 hypertension and/or carotid bruits. Follow-up was conducted by the pharmacist during subsequent visits to the pharmacy and by telephone for patients who resided in the well-elderly housing facility. Follow-up included monitoring for compliance, blood pressure control, medication changes, and lifestyle changes.
Results Fifty white patients were screened (37 women, 13 men); 25 patients were screened at each site. Screening took an average contact time of approximately 7 minutes per patient. The average age was 71. Thirty-six (72%) of the 50 patients screened had stage 1, 2, or 3 hypertension. Of those, 24 (67%) were currently taking antihypertensive medications and 6 (17%) had a medication change after being referred to their physician. Patients were given a stroke risk assessment using AHA’s stroke risk protocol. The risk profile categories are described as normal, mild, moderate, or high based on weighted points for varTable 3. Results of Patient Referrals to Physicians
Result of Intervention
Hypertension Project No.a
Stroke Project No.a
Dose increase
8
N/A
Medication change
8
4
Lifestyle change
1
4
14
2
Medication added Medication discontinued
1
0
Compliance improved
1b
2b
No change
78
26
Unknown
18
12
N/A = not applicable. a Multiple changes were implemented for 8 patients; thus, the total does not equal 121, the number of patients referred to their physician in the hypertension project. b As reported by patient at subsequent visits.
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ious risk factors. Results of the risk assessments for patients screened were normal, 4%; mild, 26%; moderate, 32%; high, 38%. Of the patients who were in the high risk category, 58% had a history of cardiovascular disease. An example of a patient screened was a 73-year-old woman with diabetes and high blood pressure currently taking antihypertensive medication. She received points as follows: age—6 points, blood pressure medication—3 points, diabetes—3 points, blood pressure reading of 146/70 mm Hg—5 points, for a total of 17 points. This patient was classified as being at high risk for stroke according to AHA criteria (see Appendix 2). No irregular pulses were detected in any of the 50 participants, with the exception of 2 participants with previously diagnosed atrial fibrillation. ECGs were not completed on these patients because of their history of documented atrial fibrillation. Medication changes as determined by patient interview and dispensing records are described in Table 3.
Discussion Our results demonstrate that community pharmacies are effective locations for identifying patients with undetected or undertreated hypertension and patients who are at risk for stroke. Unfortunately, physicians made relatively few changes in regimens after patients were referred. A change in treatment occurred in just under one-third (43 of 121) of referrals in the hypertension project and only 12% (6 of 50) of referrals in the stroke prevention project. We believe that the referral results point out the importance of collaborative programs for ongoing assessment and monitoring of patients. Pharmacists must work collaboratively with other health care providers and patients to create change. Effective marketing and education directed at local physicians before initiation of these projects should have been done. Such steps may help to improve attitudes toward collaboration in the mutual care of patients. The hypertension screening program successfully identified and referred people for additional assessment and definitive diagnosis of hypertension. The high percentage of persons with stage 1 or higher readings (82 of 165 screened, or 49.6%) who were not diagnosed with hypertension or who were unaware they were diagnosed as hypertensive correlates with published prevalence data, especially for the elderly, who made up the great majority of patients screened as part of this project. Pharmacists in the hypertension project identified significant undertreatment. Of patients on antihypertensive medications, 70% had stage 1 or higher blood pressure readings at first screening, and 28% of those had stage 2 or 3 readings. If these readings were confirmed, more than one out of four people treated with antihypertensives remained at increased risk for cardiovascular diseaserelated morbidity and mortality due to undertreatment. It is possible that more patients who knew through prior experience that they were not adequately controlled participated in the screening, possibly biasing the results to some extent. Nevertheless, our data cor-
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relate well with recently published National Health and Nutrition Examination Survey (NHANES) III, Phase II statistics that indicate that only 27% of patients with hypertension are adequately controlled.1 Pharmacist involvement in monitoring outcomes of antihypertensive drug therapy has been shown to improve compliance, reduce the incidence of adverse effects, and provide more timely recommendations for changes in treatment based on blood pressure monitoring when patients receive medication refills.6–10 The importance of atrial fibrillation as a treatable risk factor for stroke is well established. The optimal method for identifying patients with atrial fibrillation is not known. The current literature is limited but suggests that the best strategy for detecting atrial fibrillation may be screening eligible patients by nurse pulse palpation.13 AHA’s stroke risk profile is a valuable program that can be implemented in a pharmacy setting to improve patient awareness about stroke. The protocol assesses stroke risk factors, including age, systolic blood pressure, use of antihypertensive therapy, diabetes mellitus, cigarette smoking, prior cardiovascular disease (coronary artery disease, congestive heart failure, and claudication), sex, and race. Pharmacists trained in physical assessment, blood pressure assessment, and patient interviewing can easily conduct screening. Assistance is needed with ECG testing, but local clinics can often provide equipment and personnel in a collaborative effort. These projects were conducted in a well-elderly housing facility and an independent pharmacy with a community pharmacy resident and pharmacy interns available to provide patient care. Time is likely to be a greater obstacle to such advanced services in pharmacies without these resources. Many other obstacles have been cited by pharmacists considering provision of pharmaceutical care in the community pharmacy setting. These obstacles and solutions have been described and discussed previously.13,14 Areas for future research include assessment of primary care provider acceptance of community pharmacy-based screenings, evaluation of physician–pharmacist collaboration in the management of chronic disease states, determination of patient satisfaction using validated instruments, influence of screening on medication adherence, and longitudinal outcomes of disease prevention or management (e.g., blood pressure control after identification during screening, or lifestyle modification for stroke prevention). In addition, cost-effectiveness studies of pharmacists’ interventions in the community setting could help individual pharmacists in their decision to implement more screening programs.
Conclusion Through ongoing screening programs, community pharmacists are in an ideal position to screen patients at risk for cardiovascular and cerebrovascular disease. Screening programs also offer the opportunity to educate patients on risk factors for cardiovascular disease and lifestyle modifications to minimize these risks. We demonstrated that pharmacists have the ability to identify and refer at-risk patients to their physicians for further evaluation.
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The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. The results of the two projects described herein were presented in poster form at the Annual Meetings of the American Pharmaceutical Association in March 1997 and March 1998.
References 1. The Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure. The Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). Arch Intern Med 1997;157:2413–46. 2. American Heart Association. 2002 Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 2001. 3. American Heart Association. 2001 Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 2000. 4. National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group Report on Hypertension in the Elderly. Hypertension. 1993;23:275. 5. Schommer JC. Pharmacist workload and time management. Drug Topics. February 19, 2001:45.
6. McKenney JM, Slining JM, Henderson HR, et al. The effect of clinical pharmacy services on patients with essential hypertension. Circulation. 1973;48:1104–11. 7. McKenney JM, Brown ED, Necsary R, et al. Effect of pharmacist drug monitoring and patient education on hypertensive patients. Contemp Pharm Pract. 1978:1:50–6. 8. Park JJ, Kelly P, Carter BL, Burgess PP. Comprehensive pharmaceutical care in the chain setting. J Am Pharm Assoc. 1996;36:443–51. 9. Monroe WP, Kunz K, Dalmady-Israel C, et al. Economic evaluation of pharmacist involvement in disease management in a community pharmacy setting. Clin Ther. 1997;19:113–23. 10. Carter BL, Barnette DJ, Chrischilles E, et al. Evaluation of hypertensive patients after care provided by community pharmacists in a rural setting. Pharmacotherapy. 1997;17:1274–85. 11. The Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure. The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med. 1993;153:154–83. 12. Somerville S, Somerville J, Croft P, Lewis M. Atrial fibrillation: a comparison of methods to identify cases in general practice. Brit J Gen Pract. 2000;50:727–9. 13. McDonough RP, Rovers JP, Currie JD. Obstacles to the implementation of pharmaceutical care in the community setting. J Am Pharm Assoc. 1998;38:87–95. 14. Campbell RK. Confronting barriers to pharmaceutical care. J Am Pharm Assoc. 1998;38:410–2.
Appendix 1. Sample Referral Letter Date
Provider Address
Dear Dr. ____:
W e have referred ______________________ to your office as a result of their high blood pressure readings taken at Travis Pharmacy. After they rested for at least five minutes, their blood pressure was obtained as ________/___________. They have been advised to seek your advice within the following time frame: _______________________. Attached is a table listing all blood pressures taken at the pharmacy in the recent past. If you have any questions, please contact me at: (XXX) XXX-XXXX.
Sincerely: ____________________________________________ Pharmacist Date
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Systolic Blood Pressure
Journal of the American Pharmaceutical Association
Diastolic Blood Pressure
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Appendix 2 Stroke Risk Assessment Tool For Office Use Only
American Heart Association, Iowa Affiliate
Hospital:_____ Pt. Initials: _______ No. ________
STROKE RISK PROFILE
HISTORY
Points
Are you
Female ____
Male ______
Are you
African American_____
Latino _____
White_____
Other _____
_____
_____
_____
Are you taking medication for high blood pressure?
Yes_____
No_____
_____
Are you taking aspirin on a daily basis?
Yes_____
No_____
Are you taking warfarin?
Yes_____
No_____
Yes_____
No_____
_____
Yes_____
No_____
_____
No_____
_____
Age Medication
Diabetes Do you have diabetes?
Cigarettes Do you currently smoke cigarettes?
Cardiovascular disease (coronary artery disease, congestive heart failure, claudication) Have you ever had a heart attack, angina, heart failure, or pain in your legs from blocked blood vessels?
Yes_____
Cerebrovascular disease (24 hours of focal weakness or sensory loss or loss of speech or vision) Have you ever had a stroke?
Yes_____
No_____
Have you ever had a transient ischemic attack?
Yes_____
No_____
Yes_____
No_____
Yes_____
No_____
Atrial fibrillation
Yes_____
No_____
_____
Left ventricular hypertrophy
Yes_____
No_____
_____
EXAMINATION
Pulse Regular
Carotid Bruit
Electrocardiogram
Blood Pressure Systolic
_____
Diastolic
_____ Total Points _____
INFORMATION TO PATIENT
Stroke Risk Profile Normal_____ Mild_____ Moderate_____ High_____ Original – American Heart Association
Copy – Participant Please share this information with your doctor
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Identifying At-Risk Patients Through Community PharmacyBased Hypertension and Stroke Prevention Screening Projects Stacy A. Mangum, Kim R. Kraenow, and Warren A. Narducci
Objective: To demonstrate whether a community pharmacist can be successful in identifying and referring patients with elevated blood pressure and/or increased risk of stroke. Setting: An independent community pharmacy and well-elderly housing facility in rural Iowa. Practice Description: The pharmacy had dedicated space for patient care activities, had a community pharmacy practice resident, and served as a clerkship site for a local school of pharmacy. One of three well-elderly housing facilities in the same community was used as a screening site for the stroke prevention program. Practice Innovation: All adults entering the pharmacy during the time the blood pressure project was underway were offered a free blood pressure screening. If readings were elevated, patients were referred to their primary care provider. For stroke prevention, a screening using the American Heart Association stroke risk assessment protocol was held at the pharmacy and the well-elderly housing facility. Main Outcome Measures: Blood pressure categories and stroke risk (normal, mild, moderate, and high) categories obtained during the screening. Results: A total of 351 patients were screened for hypertension. Of these, 216 (62%) had readings greater than 140/90 mm Hg. Of the 121 patients referred to their physician, 43 (36%) had a regimen change. A total of 50 patients were screened for stroke risk. Results of the risk assessments for patients screened were normal, 4%; mild, 26%; moderate, 32%; high, 38%. Conclusion: These projects demonstrated that, through ongoing screening programs, community pharmacists are in an ideal position to screen patients at risk for cardiovascular and cerebrovascular disease and refer patients to their physicians for further evaluation.
Keywords: Stroke, hypertension, community pharmacy, ambulatory care, patient education, counseling, screening. J Am Pharm Assoc. 2003;43:50–5.
Hypertension is a major risk factor for cardiovascular morbidity and mortality from coronary artery disease (including ischemic heart disease, myocardial infarction, and sudden death), cardiac disease (left ventricular hypertrophy and congestive heart failure), renal failure, and blindness. Hypertension also greatly increases the risk for developing cerebrovascular disease. At least 50 million people in the United States have elevated blood pressure, and, according to the Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI), the rates of awareness, treatment, and control of hyperReceived March 4, 2002, and in revised form May 29, 2002. Accepted for publication August 21, 2002. Stacy A. Mangum, PharmD, is clinical assistant professor; Kim R. Kraenow, PharmD, is clinical assistant professor, School of Pharmacy, University of Missouri–Kansas City. Warren A. Narducci, PharmD, is owner and pharmacist in charge, Nishna Valley Pharmacy, Shenandoah, Iowa. Correspondence: Stacy A. Mangum, PharmD, School of Pharmacy, University of Missouri–Kansas City, M3-C19 Medical School, 2411 Holmes Street, Kansas City, MO 64108-2792. Fax: 816-753-0804. E-mail: [email protected].
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tension have declined slightly in recent years.1 Stroke is the leading cause of disability and the third leading killer in America. In 1999 strokes killed 167,366 people, accounting for about 1 of every 14.3 deaths.2 The American Heart Association (AHA) has identified several factors that influence the risk of stroke, including increasing age, male sex, heredity, race, prior stroke, high blood pressure, cigarette smoking, diabetes mellitus, carotid artery disease, heart disease, transient ischemic attacks, high red blood cell count, and sickle cell anemia.3 JNC VI suggests that community screening for high blood pressure is an important strategy for primary prevention of hypertension.1,4 Screening programs are also vital for monitoring progress and promoting adherence to therapy for high blood pressure and identifying patients at increased risk for stroke. Community pharmacists are in a strong position to identify patients at risk for cardiovascular and cerebrovascular disease through simple hypertension and stroke screening programs. The potential benefit of screening is supported by a 1999 study conducted by researchers at the University of Minnesota and Ohio State University in which community pharmacists reported an average of 59 face-to-face interactions with individuals daily.5 In
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fact, positive clinical, economic, and humanistic outcomes have been demonstrated in hypertensive patients receiving comprehensive pharmaceutical care in community pharmacies.6–10 Despite these demonstrated benefits, relatively few community pharmacists regularly screen their patients for hypertension or other risk factors for cerebrovascular disease. This may be due to the assumption that formal programs such as those described in the previously cited studies are too difficult or time-consuming for the average community pharmacist. In this article we describe two screening projects conducted at Travis Pharmacy (now Nishna Valley Pharmacy), an independent community pharmacy in Shenandoah, Iowa, (pop. approximately 6,000) that serves as a community pharmacy residency and clerkship site for the University of Nebraska Medical Center College of Pharmacy. We hope that by sharing the results of our screening projects we will encourage other community pharmacists to implement similar services.
Hypertension Project O bjective The objective of the hypertension screening project was to demonstrate whether a community pharmacist can be successful in identifying and referring patients with elevated blood pressure. Practice Innovation Adults who entered the pharmacy between July 15, 1996, and February 11, 1997, were offered a free blood pressure screening. Systolic and diastolic blood pressures were measured by a pharmacist or pharmacy student using the Dynapulse 200M computerized cardiovascular monitoring system (Pulse Metric, Inc., San Diego, Calif.). Patients rested in a chair for 5 minutes before their blood pressure was measured. During this time, the pharmacist or pharmacy student collected patient data, including date of birth, current medication use, diagnosis, primary care provider’s name, normal blood pressure if known, and any lifestyle factors that can affect blood pressure (e.g., caffeine intake, food ingestion, exercise, smoking, etc.). In addition, patients taking antihypertensive medications were asked to estimate how often they missed a dose of that medication. Compliance counseling was then provided to determine the cause of noncompliance and to suggest possible solutions to the problem. When a blood pressure reading was elevated, the pharmacist or pharmacy student waited at least 2 minutes and then took the reading again. If the reading was still elevated, the patient’s blood pressure was taken manually (using a stethoscope and sphygmomanometer) by the community pharmacy practice resident, who was the project coordinator. All blood pressure readings were originally stratified according to JNC V11 classifications and subsequently reclassified using the revised JNC VI categories (see Table 1). All patients with blood pressures indicating stage 1
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hypertension or higher were counseled regarding recommended course of action on the basis of the JNC V treatment guidelines.11 So as not to overwhelm local physicians with referrals, patients previously diagnosed with hypertension who reported being followed by their physician were only referred if their blood pressure reading at the screening was higher than their usual readings or indicated stage 2 hypertension or higher. Patients not previously diagnosed as hypertensive, but with stage 1 or higher blood pressure readings, were also referred. Each patient who was referred was given a written description of the intervention to give their physician (see Appendix 1). Any patients with stage 2 or higher readings were referred to their physician. To make this referral, the pharmacist called the physician, while the patient waited, to determine when the physician could see the patient. In addition, a follow-up intervention form describing the blood pressure reading at the pharmacy and the date of referral was sent to the physician. Referred patients were advised to follow up with the pharmacist after they had seen their physician. Upon his or her return to the pharmacy, the patient’s blood pressure was again taken and recorded in his or her chart. Compliance counseling similar to that given on the first visit was conducted at each visit to encourage adherence to the prescribed regimen.
Results A total of 351 patients were screened. Of these, 181 (52%) patients had an existing diagnosis of primary hypertension, 5 (1%) had secondary hypertension, 103 (29%) had not received a previous diagnosis (i.e., were unaware of their blood pressures), and 62 (18%) were unsure about their diagnosis (see Table 2). The average age of the patients was 63 years (range, 19 to 94). Because of community population demographics, all except two of the people screened (both Hispanic) were white. Forty percent of the participants were men and 60% were women. The number of follow-up visits to the pharmacy made by each patient ranged from two to four. One hundred twenty-one patients (34%) were referred to their physician. Forty-three (36%) had a regimen change as a result of this referral, as determined by patient interview and review of dispensing records (see Table 3). Of the Table 1. Classification of Blood Pressure for Adults Age 18 and Older Category
Systolic (mm Hg)
Optimal
< 120
and
< 80
Normal
< 130
and
< 85
130– 139
or
85– 89
Stage 1
140– 159
or
90– 99
Stage 2
160– 179
or
100– 109
High-normal
Diastolic (mm Hg)
Hypertension
Stage 3
180
or
110
Source: Reference 1.
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Table 2. Hypertension Stage by Existing Diagnosis: Blood Pressure Reading at First Screening
Existing Diagnosis at Screening Primary hypertension Secondary hypertension Unaware/unknown
JNC VI Stage Classification (No.)1 1 2 3
Normal No.
High–Normal No.
Total No.
25
27
79
37
13
0
0
4
1
0
5
47
36
63
15
4
165
181
JNC VI = Sixth Report of the Joint National Committee on Detection, Evaluation, and Teatment of High Blood Pressure.
103 subjects who did not have a preexisting diagnosis of hypertension, 47 (46%) were referred to their physician, and 6 (6%) were subsequently diagnosed as hypertensive and started on antihypertensive therapy. At their first screening, 184 patients (52% of those screened) were taking at least one antihypertensive medication. Of these, 129 (70%) had readings indicating stage 1 hypertension or higher at the first screening.
Stroke Prevention Project O bjective The objective of this project was to demonstrate whether a community pharmacist can be successful in identifying and referring patients with increased risk of stroke based on AHA’s screening and stroke risk assessment protocol. Practice Innovation A 1-day stroke prevention screening using AHA’s stroke risk assessment protocol provided by the AHA Iowa affiliate was held at Travis Pharmacy and a well-elderly housing facility. The screening was advertised during a “Talk With Your Pharmacist” radio segment and by posting flyers at both screening locations. Patients who volunteered to participate were asked to sign a liability waiver and a release of information form. Screenings were completed by pharmacists with expertise in blood pressure assessment and a physician assistant who was skilled in physical diagnosis and electrocardiography. The AHA Iowa affiliate provided information and written materials on risks associated with stroke. A brief medical history was obtained to determine an individual’s risk for stroke. Data obtained included sex, age, diagnosis of diabetes, cardiovascular and/or cerebrovascular disease, blood pressure medication use, and history of cigarette smoking. Based on AHA’s risk assessment protocol, point values were assigned for specific risk factors, and the total score on the Stroke Risk Profile was used to stratify patients into normal, mild, moderate, and high risk groups (see Appendix 2). A physical examination consisting of blood pressure, pulse, and carotid bruit evaluation was completed on each patient. When an irregular pulse was detected, a standard three-lead electrocardiogram
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(ECG) was performed. Points were given for systolic blood pressure measurements and based on ECG results, including atrial fibrillation or left ventricular hypertrophy on the basis of AHA criteria. After calculating an individual’s score, pharmacists explained the risk for stroke to the patient and discussed ways to reduce risk and identify warning signs for stroke. Letters were sent to physicians informing them of patients who had stage 1, 2, or 3 hypertension and/or carotid bruits. Follow-up was conducted by the pharmacist during subsequent visits to the pharmacy and by telephone for patients who resided in the well-elderly housing facility. Follow-up included monitoring for compliance, blood pressure control, medication changes, and lifestyle changes.
Results Fifty white patients were screened (37 women, 13 men); 25 patients were screened at each site. Screening took an average contact time of approximately 7 minutes per patient. The average age was 71. Thirty-six (72%) of the 50 patients screened had stage 1, 2, or 3 hypertension. Of those, 24 (67%) were currently taking antihypertensive medications and 6 (17%) had a medication change after being referred to their physician. Patients were given a stroke risk assessment using AHA’s stroke risk protocol. The risk profile categories are described as normal, mild, moderate, or high based on weighted points for varTable 3. Results of Patient Referrals to Physicians
Result of Intervention
Hypertension Project No.a
Stroke Project No.a
Dose increase
8
N/A
Medication change
8
4
Lifestyle change
1
4
14
2
Medication added Medication discontinued
1
0
Compliance improved
1b
2b
No change
78
26
Unknown
18
12
N/A = not applicable. a Multiple changes were implemented for 8 patients; thus, the total does not equal 121, the number of patients referred to their physician in the hypertension project. b As reported by patient at subsequent visits.
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ious risk factors. Results of the risk assessments for patients screened were normal, 4%; mild, 26%; moderate, 32%; high, 38%. Of the patients who were in the high risk category, 58% had a history of cardiovascular disease. An example of a patient screened was a 73-year-old woman with diabetes and high blood pressure currently taking antihypertensive medication. She received points as follows: age—6 points, blood pressure medication—3 points, diabetes—3 points, blood pressure reading of 146/70 mm Hg—5 points, for a total of 17 points. This patient was classified as being at high risk for stroke according to AHA criteria (see Appendix 2). No irregular pulses were detected in any of the 50 participants, with the exception of 2 participants with previously diagnosed atrial fibrillation. ECGs were not completed on these patients because of their history of documented atrial fibrillation. Medication changes as determined by patient interview and dispensing records are described in Table 3.
Discussion Our results demonstrate that community pharmacies are effective locations for identifying patients with undetected or undertreated hypertension and patients who are at risk for stroke. Unfortunately, physicians made relatively few changes in regimens after patients were referred. A change in treatment occurred in just under one-third (43 of 121) of referrals in the hypertension project and only 12% (6 of 50) of referrals in the stroke prevention project. We believe that the referral results point out the importance of collaborative programs for ongoing assessment and monitoring of patients. Pharmacists must work collaboratively with other health care providers and patients to create change. Effective marketing and education directed at local physicians before initiation of these projects should have been done. Such steps may help to improve attitudes toward collaboration in the mutual care of patients. The hypertension screening program successfully identified and referred people for additional assessment and definitive diagnosis of hypertension. The high percentage of persons with stage 1 or higher readings (82 of 165 screened, or 49.6%) who were not diagnosed with hypertension or who were unaware they were diagnosed as hypertensive correlates with published prevalence data, especially for the elderly, who made up the great majority of patients screened as part of this project. Pharmacists in the hypertension project identified significant undertreatment. Of patients on antihypertensive medications, 70% had stage 1 or higher blood pressure readings at first screening, and 28% of those had stage 2 or 3 readings. If these readings were confirmed, more than one out of four people treated with antihypertensives remained at increased risk for cardiovascular diseaserelated morbidity and mortality due to undertreatment. It is possible that more patients who knew through prior experience that they were not adequately controlled participated in the screening, possibly biasing the results to some extent. Nevertheless, our data cor-
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relate well with recently published National Health and Nutrition Examination Survey (NHANES) III, Phase II statistics that indicate that only 27% of patients with hypertension are adequately controlled.1 Pharmacist involvement in monitoring outcomes of antihypertensive drug therapy has been shown to improve compliance, reduce the incidence of adverse effects, and provide more timely recommendations for changes in treatment based on blood pressure monitoring when patients receive medication refills.6–10 The importance of atrial fibrillation as a treatable risk factor for stroke is well established. The optimal method for identifying patients with atrial fibrillation is not known. The current literature is limited but suggests that the best strategy for detecting atrial fibrillation may be screening eligible patients by nurse pulse palpation.13 AHA’s stroke risk profile is a valuable program that can be implemented in a pharmacy setting to improve patient awareness about stroke. The protocol assesses stroke risk factors, including age, systolic blood pressure, use of antihypertensive therapy, diabetes mellitus, cigarette smoking, prior cardiovascular disease (coronary artery disease, congestive heart failure, and claudication), sex, and race. Pharmacists trained in physical assessment, blood pressure assessment, and patient interviewing can easily conduct screening. Assistance is needed with ECG testing, but local clinics can often provide equipment and personnel in a collaborative effort. These projects were conducted in a well-elderly housing facility and an independent pharmacy with a community pharmacy resident and pharmacy interns available to provide patient care. Time is likely to be a greater obstacle to such advanced services in pharmacies without these resources. Many other obstacles have been cited by pharmacists considering provision of pharmaceutical care in the community pharmacy setting. These obstacles and solutions have been described and discussed previously.13,14 Areas for future research include assessment of primary care provider acceptance of community pharmacy-based screenings, evaluation of physician–pharmacist collaboration in the management of chronic disease states, determination of patient satisfaction using validated instruments, influence of screening on medication adherence, and longitudinal outcomes of disease prevention or management (e.g., blood pressure control after identification during screening, or lifestyle modification for stroke prevention). In addition, cost-effectiveness studies of pharmacists’ interventions in the community setting could help individual pharmacists in their decision to implement more screening programs.
Conclusion Through ongoing screening programs, community pharmacists are in an ideal position to screen patients at risk for cardiovascular and cerebrovascular disease. Screening programs also offer the opportunity to educate patients on risk factors for cardiovascular disease and lifestyle modifications to minimize these risks. We demonstrated that pharmacists have the ability to identify and refer at-risk patients to their physicians for further evaluation.
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The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. The results of the two projects described herein were presented in poster form at the Annual Meetings of the American Pharmaceutical Association in March 1997 and March 1998.
References 1. The Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure. The Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). Arch Intern Med 1997;157:2413–46. 2. American Heart Association. 2002 Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 2001. 3. American Heart Association. 2001 Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 2000. 4. National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group Report on Hypertension in the Elderly. Hypertension. 1993;23:275. 5. Schommer JC. Pharmacist workload and time management. Drug Topics. February 19, 2001:45.
6. McKenney JM, Slining JM, Henderson HR, et al. The effect of clinical pharmacy services on patients with essential hypertension. Circulation. 1973;48:1104–11. 7. McKenney JM, Brown ED, Necsary R, et al. Effect of pharmacist drug monitoring and patient education on hypertensive patients. Contemp Pharm Pract. 1978:1:50–6. 8. Park JJ, Kelly P, Carter BL, Burgess PP. Comprehensive pharmaceutical care in the chain setting. J Am Pharm Assoc. 1996;36:443–51. 9. Monroe WP, Kunz K, Dalmady-Israel C, et al. Economic evaluation of pharmacist involvement in disease management in a community pharmacy setting. Clin Ther. 1997;19:113–23. 10. Carter BL, Barnette DJ, Chrischilles E, et al. Evaluation of hypertensive patients after care provided by community pharmacists in a rural setting. Pharmacotherapy. 1997;17:1274–85. 11. The Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure. The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med. 1993;153:154–83. 12. Somerville S, Somerville J, Croft P, Lewis M. Atrial fibrillation: a comparison of methods to identify cases in general practice. Brit J Gen Pract. 2000;50:727–9. 13. McDonough RP, Rovers JP, Currie JD. Obstacles to the implementation of pharmaceutical care in the community setting. J Am Pharm Assoc. 1998;38:87–95. 14. Campbell RK. Confronting barriers to pharmaceutical care. J Am Pharm Assoc. 1998;38:410–2.
Appendix 1. Sample Referral Letter Date
Provider Address
Dear Dr. ____:
W e have referred ______________________ to your office as a result of their high blood pressure readings taken at Travis Pharmacy. After they rested for at least five minutes, their blood pressure was obtained as ________/___________. They have been advised to seek your advice within the following time frame: _______________________. Attached is a table listing all blood pressures taken at the pharmacy in the recent past. If you have any questions, please contact me at: (XXX) XXX-XXXX.
Sincerely: ____________________________________________ Pharmacist Date
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Systolic Blood Pressure
Journal of the American Pharmaceutical Association
Diastolic Blood Pressure
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Appendix 2 Stroke Risk Assessment Tool For Office Use Only
American Heart Association, Iowa Affiliate
Hospital:_____ Pt. Initials: _______ No. ________
STROKE RISK PROFILE
HISTORY
Points
Are you
Female ____
Male ______
Are you
African American_____
Latino _____
White_____
Other _____
_____
_____
_____
Are you taking medication for high blood pressure?
Yes_____
No_____
_____
Are you taking aspirin on a daily basis?
Yes_____
No_____
Are you taking warfarin?
Yes_____
No_____
Yes_____
No_____
_____
Yes_____
No_____
_____
No_____
_____
Age Medication
Diabetes Do you have diabetes?
Cigarettes Do you currently smoke cigarettes?
Cardiovascular disease (coronary artery disease, congestive heart failure, claudication) Have you ever had a heart attack, angina, heart failure, or pain in your legs from blocked blood vessels?
Yes_____
Cerebrovascular disease (24 hours of focal weakness or sensory loss or loss of speech or vision) Have you ever had a stroke?
Yes_____
No_____
Have you ever had a transient ischemic attack?
Yes_____
No_____
Yes_____
No_____
Yes_____
No_____
Atrial fibrillation
Yes_____
No_____
_____
Left ventricular hypertrophy
Yes_____
No_____
_____
EXAMINATION
Pulse Regular
Carotid Bruit
Electrocardiogram
Blood Pressure Systolic
_____
Diastolic
_____ Total Points _____
INFORMATION TO PATIENT
Stroke Risk Profile Normal_____ Mild_____ Moderate_____ High_____ Original – American Heart Association
Copy – Participant Please share this information with your doctor
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