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Impact of a pharmacist and nurse led clinic on patient blood pressure control
Journal of Interprofessional Education & Practice 8 (2017) 57e59
Contents lists available at ScienceDirect
Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com
Impact of a pharmacist and nurse led clinic on patient blood pressure control Alexander DeLucenay a, b, *, Kelly Curran c, Angela Karnes b a
St. John Fisher College, 3690 East Ave, Rochester, NY 14618, United States Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621, United States c Virginia Baptist Hospital, 3300 Rivermont Avenue, Lynchburg VA 24503, United States b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 May 2016 Received in revised form 9 June 2017 Accepted 28 June 2017
Background: Studies suggest that uncontrolled hypertension may be due to patients' lack of adherence to medications or diet. Pharmacists and nurses have been shown to be uniquely qualified to assist in the care of these patients. Purpose: To see if a hypertension clinic run by a pharmacist and registered nurse can help patients obtain blood pressure control. Methods: The experimental group consisted of patients with uncontrolled hypertension whose physician referred them to a hypertension clinic that is operated by a pharmacist and a registered nurse for three visits. The patient's initial visit to the clinic and only the first 3 visits were analyzed. The control group includes patients with hypertension that are not seen at the hypertension clinic. The average reduction in systolic and diastolic blood pressure and the status of blood pressure goal achievement with the JNC VIII guideline will be compared to the control group using appropriate statistical tests. Results: The percentage of patients at their goal blood pressure was 59.4% in the pharmacist/nurse clinic, compared to 33.3% in the primary care provider clinic (p ¼ 0.048). Conclusion: The intervention of an interdisciplinary collaborative drug therapy management-certified pharmacist and registered nurse both statistically and clinically significantly improved the care of patients with hypertension. © 2017 Elsevier Inc. All rights reserved.
Keywords: Hypertension Collaborative drug therapy management Interdisciplinary Pharmacist Nurse Clinic
1. Introduction Hypertension remains a leading risk factor of death in the world today. The American Heart Association stated that hypertension was listed as the primary or contributing cause of death in more than 348,000 Americans in 2009.1 It is estimated that approximately 40% of the world's population has raised blood pressure, and nearly 1 billion people still remain uncontrolled despite existence of antihypertensive medications.2 Studies suggest that even small decreases in blood pressure can help decrease the rate of mortality in this patient population.3 Many times, lack of adherence by patients and use of suboptimal choices of drug therapy contribute to the inadequate control of blood pressure.4
* Corresponding author. St. John Fisher College, 3690 East Ave, Rochester, NY 14618, United States. E-mail addresses: [email protected] (A. DeLucenay), Kellycurran25@gmail. com (K. Curran), [email protected] (A. Karnes). http://dx.doi.org/10.1016/j.xjep.2017.06.003 2405-4526/© 2017 Elsevier Inc. All rights reserved.
Different methods for improving blood pressure control are needed. One such method is the collaboration between interdisciplinary medical teams. Pharmacists are uniquely qualified to discuss patients' medications, adverse effects, and adherence to medications. In many settings, pharmacists also have the ability to make adjustments to medications as necessary and monitor efficacy and toxicity of pharmacotherapy.4 The expertise of a pharmacist affords him or her the ability to decipher which medication is best for the patient's blood pressure management with thorough evaluation of the appropriate medication regimen necessary for each patient to reach his or her blood pressure goal in addition to optimizing lifestyle modifications. Literature demonstrates the benefit of interdisciplinary approach to blood pressure management involving pharmacists. In one systematic review, the majority of the studies favored pharmacist intervention. This review included 30 randomized controlled trials (RCTs), containing 11,765 patients in the analysis. The pooled result revealed a statistically significant reduction of blood pressure in the pharmacist intervention group.5 In a second meta-analysis, 39 RCTs
58
A. DeLucenay et al. / Journal of Interprofessional Education & Practice 8 (2017) 57e59
were analyzed to reveal that pharmacist intervention (either alone or in combination with other healthcare practitioners) resulted in larger decreases in both systolic and diastolic blood pressure.6 2. Objectives To assess if a hypertension clinic run by a pharmacist with collaborative drug therapy management privileges and a registered nurse can help patients obtain blood pressure control. 3. Methods Patients in an internal medicine clinic comprised of 75% Medicaid population and 25% English as a second language (ESL) were divided into two groups: standard of care (control) and the pharmacist/nurse managed (experimental) group in the hypertension clinic. The experimental group consisted of patients with uncontrolled hypertension as identified by their primary care physician, who were referred to a hypertension clinic that is operated by a pharmacist and a registered nurse. Uncontrolled hypertension was defined as patients who were not at their patient specific blood pressure goal as defined in the JNC VIII Guidelines with pharmacologic and/or nonpharmacologic therapy, which was followed by both the experimental and control group.7 (Table 1) Patients included in the experimental groupwere selected sequentially and included those who had at least 3 visits with the pharmacist/nurse clinic, the second visit being no longer than 3 months after the first. Blood pressures were recorded from the first and third visits using an automated cuff. Patients in the control group were selected using the same criteria as above, and never seen by the pharmacist/nurse hypertension clinic. On average, each visit was at least two weeks apart, with the first and third visits being at least 4 weeks apart. Both groups had visits analyzed in the same time frame. Each visit was 30 min long, and patients were first educated by the registered nurse on lifestyle changes including the Dietary Approaches to Stop Hypertension (DASH) diet and exercise.8 The patients were then seen by the pharmacist who assessed compliance with their current medications, and assessed for any adverse drug reactions. Based on the patients' blood pressure at that visit, and their home blood pressure readings if available, the pharmacist was able to prescribe medications, including adjusting doses of their current antihypertensive medications, adding additional agents, or discontinuing medications at their discretion. The pharmacist was also able to order laboratory tests in order to monitor the side effects (serum creatinine, potassium) and efficacy of drug therapy. The control group included patients with uncontrolled hypertension that were not seen at the hypertension clinic. These patients saw their primary care providers who were either an attending physician, resident-in-training, nurse practitioner, or physician assistant. These patients were identified retrospectively through the electronic medical record system. Patients were selected sequentially through identifying patients whose blood pressure was not at goal and had 3 additional visits to their primary care provider, the first two being within 3 months to mirror the
experimental group. None of the patients followed any particular regimen or drug class to attain blood pressure control. Both groups utilized JNC-7 guidelines (current at that point in time) to guide therapy-based decisions. Adherence was assessed at every visit to both groups, but special importance was placed at visits in the experimental group with the pharmacist and registered nurse. The average reduction in systolic blood pressure, diastolic blood pressure and the status of blood pressure goal achievement were recorded. A Fisher's Exact test was performed to compare the goal blood pressure status of the experimental and control groups, with statistically significant values set at p < 0.05. Our goal was to determine if the interdisciplinary clinic showed any improvement in blood pressure control based on goal blood pressure achievement in our setting. The study was submitted to the Rochester Regional Health Instuitional Review Board for approval. 4. Results A total of 65 patients' blood pressures were evaluated, including 32 patients in the experimental group, and 33 from the control group. In the experimental group, the average systolic blood pressures dropped from 162 mmHg to 143 mmHg, and diastolic blood pressures dropped from 87 mmHg to 79 mmHg. In contrast, the control group's patients' average blood pressures dropped from 161 mmHg to 145 mmHg, and diastolic blood pressures dropped from 83 mmHg to 78 mmHg. The percentage of patients at their goal blood pressure was 59.4% in the experimental group, compared to 33.3% in the control group (p ¼ 0.048). (Fig. 1). Of note, 4 patients in the control group had the higher goal of 150/90 compared to 7 patients in the experimental group. 5. Discussion There is a mounting body of literature that supports the role of the pharmacist in interdisciplinary settings assisting in managing chronic disease states such as hypertension.5,6 With the shortage of physicians practicing in primary care and the influx of patients into the healthcare system, interdisciplinary teams working alongside physician counterparts will be needed to assist in providing quality care to patients. Pharmacists have the unique ability to discuss medication therapy at length with patients, which allow patients to more fully understand the treatment prescribed by their primary care provider. This affords the patients the knowledge that may give them more confidence in their medication regimen, leading to improving adherence. In addition, nurses have a very strong skill set in being able to provide education and resources to patients for not only lifestyle changes, but also assist with psycho-social situations that may be inhibiting the patients from achieving their healthcare
Table 1 Goal blood pressures. Qualifier
Goal Blood Pressure
Age <60 Age >60, no diabetes or kidney disease Age >60, diabetes or kidney disease
<140/<90 <150/<90 <140/<90
Fig. 1. Percentage of patients at goal.
A. DeLucenay et al. / Journal of Interprofessional Education & Practice 8 (2017) 57e59
goals. It should be noted that although the percentage drop in blood pressure in each group was relatively comparable, the goal achievement was higher in the experimental group. This is most likely due to the fact that the focus was specifically on hypertension, and the usual care group likely had many different ailments addressed at each visit with the primary care provider. Therefore, there was a very high importance placed on achieving a specific goal in the pharmacist/nurse group. 6. Limitations One of our limitations was the small sample size. The patient population was limited due to the fact that the clinic was relatively new, and did not yet have a large amount of patients. In addition, patients referred to the experimental group were generally seen as more difficult to obtain goal blood pressures. However, this gives credence to the pharmacist/nurse clinic as it can be perceived that these patients that had a more difficult time achieving their goal blood pressures were managed very effectively using the interdisciplinary approach. An additional limitation of our study was the lack of control for the change in blood pressure when comparing those at goal; we consider this study to provide preliminary evidence; however, further studies assessing change in blood pressure are needed. 7. Conclusion Interdisciplinary care with a nurse and pharmacist with collaborative drug therapy privileges leads to a statistically significant improvement in patients achieving goal blood pressure compared to standard of care. This adds to the body of literature demonstrating the value of pharmacists in interdisciplinary primary care. This is of utmost importance in today's healthcare environment where there are shortages of primary care healthcare providers and finite numbers of healthcare dollars. With the demonstration of the success of allied health providers in assisting in the care of patients alongside our physician colleagues, we are
59
able to further expand the role of these team members to work in collaboration to provide excellent patient care. As healthcare continues to move towards preventative care, pharmacists and nurses alike will be able to utilize their skill sets to improve patient outcomes. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of interest The Authors declare that there is no conflict of interest. References 1. Go AS, Mozaffarian D, Roger VL, et al. On behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics d2013 update: a report from the American Heart Association. Circulation. 2013;127:e6ee245. 2. Global Health Observatory (GHO) data. Raised blood pressure. Accessed April1 http://www.who.int/gho/ncd/risk_factors/blood_pressure_prevalence_text/en/; 2015. 3. Borenstein JE, Graber G, Saltiel E, et al. Physician- pharmacist comanagement of hypertension: a randomized, comparative trial. Pharmacotherapy. 2003;23(2): 209e216. 4. Vivian EM. Improving blood pressure control in pharmacist- managed hypertension clinic. Pharmacotherapy. 2002;22(12):1533e1540. 5. Santschi V, Chiolero A, Burnand B, et al. Impact of pharmacist care in the management of cardiovascular disease risk factors. Arch Intern Med. 2011;171(16):1441e1453. 6. Santschi V, Chiolero A, Colosimo AL, et al. Improving blood pressure control through pharmacist interventions: a meta-analysis of randomized controlled trials. J Am Heart Assoc. 2014;3. e000718. 7. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults. report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2013 Dec 18;311(5):508e520. 8. Description of the DASH Diet. National Heart Lung and Blood Institute; 2016, September. Retrieved from https://www.nhlbi.nih.gov/health/health-topics/ topics/dash/.
Contents lists available at ScienceDirect
Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com
Impact of a pharmacist and nurse led clinic on patient blood pressure control Alexander DeLucenay a, b, *, Kelly Curran c, Angela Karnes b a
St. John Fisher College, 3690 East Ave, Rochester, NY 14618, United States Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621, United States c Virginia Baptist Hospital, 3300 Rivermont Avenue, Lynchburg VA 24503, United States b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 May 2016 Received in revised form 9 June 2017 Accepted 28 June 2017
Background: Studies suggest that uncontrolled hypertension may be due to patients' lack of adherence to medications or diet. Pharmacists and nurses have been shown to be uniquely qualified to assist in the care of these patients. Purpose: To see if a hypertension clinic run by a pharmacist and registered nurse can help patients obtain blood pressure control. Methods: The experimental group consisted of patients with uncontrolled hypertension whose physician referred them to a hypertension clinic that is operated by a pharmacist and a registered nurse for three visits. The patient's initial visit to the clinic and only the first 3 visits were analyzed. The control group includes patients with hypertension that are not seen at the hypertension clinic. The average reduction in systolic and diastolic blood pressure and the status of blood pressure goal achievement with the JNC VIII guideline will be compared to the control group using appropriate statistical tests. Results: The percentage of patients at their goal blood pressure was 59.4% in the pharmacist/nurse clinic, compared to 33.3% in the primary care provider clinic (p ¼ 0.048). Conclusion: The intervention of an interdisciplinary collaborative drug therapy management-certified pharmacist and registered nurse both statistically and clinically significantly improved the care of patients with hypertension. © 2017 Elsevier Inc. All rights reserved.
Keywords: Hypertension Collaborative drug therapy management Interdisciplinary Pharmacist Nurse Clinic
1. Introduction Hypertension remains a leading risk factor of death in the world today. The American Heart Association stated that hypertension was listed as the primary or contributing cause of death in more than 348,000 Americans in 2009.1 It is estimated that approximately 40% of the world's population has raised blood pressure, and nearly 1 billion people still remain uncontrolled despite existence of antihypertensive medications.2 Studies suggest that even small decreases in blood pressure can help decrease the rate of mortality in this patient population.3 Many times, lack of adherence by patients and use of suboptimal choices of drug therapy contribute to the inadequate control of blood pressure.4
* Corresponding author. St. John Fisher College, 3690 East Ave, Rochester, NY 14618, United States. E-mail addresses: [email protected] (A. DeLucenay), Kellycurran25@gmail. com (K. Curran), [email protected] (A. Karnes). http://dx.doi.org/10.1016/j.xjep.2017.06.003 2405-4526/© 2017 Elsevier Inc. All rights reserved.
Different methods for improving blood pressure control are needed. One such method is the collaboration between interdisciplinary medical teams. Pharmacists are uniquely qualified to discuss patients' medications, adverse effects, and adherence to medications. In many settings, pharmacists also have the ability to make adjustments to medications as necessary and monitor efficacy and toxicity of pharmacotherapy.4 The expertise of a pharmacist affords him or her the ability to decipher which medication is best for the patient's blood pressure management with thorough evaluation of the appropriate medication regimen necessary for each patient to reach his or her blood pressure goal in addition to optimizing lifestyle modifications. Literature demonstrates the benefit of interdisciplinary approach to blood pressure management involving pharmacists. In one systematic review, the majority of the studies favored pharmacist intervention. This review included 30 randomized controlled trials (RCTs), containing 11,765 patients in the analysis. The pooled result revealed a statistically significant reduction of blood pressure in the pharmacist intervention group.5 In a second meta-analysis, 39 RCTs
58
A. DeLucenay et al. / Journal of Interprofessional Education & Practice 8 (2017) 57e59
were analyzed to reveal that pharmacist intervention (either alone or in combination with other healthcare practitioners) resulted in larger decreases in both systolic and diastolic blood pressure.6 2. Objectives To assess if a hypertension clinic run by a pharmacist with collaborative drug therapy management privileges and a registered nurse can help patients obtain blood pressure control. 3. Methods Patients in an internal medicine clinic comprised of 75% Medicaid population and 25% English as a second language (ESL) were divided into two groups: standard of care (control) and the pharmacist/nurse managed (experimental) group in the hypertension clinic. The experimental group consisted of patients with uncontrolled hypertension as identified by their primary care physician, who were referred to a hypertension clinic that is operated by a pharmacist and a registered nurse. Uncontrolled hypertension was defined as patients who were not at their patient specific blood pressure goal as defined in the JNC VIII Guidelines with pharmacologic and/or nonpharmacologic therapy, which was followed by both the experimental and control group.7 (Table 1) Patients included in the experimental groupwere selected sequentially and included those who had at least 3 visits with the pharmacist/nurse clinic, the second visit being no longer than 3 months after the first. Blood pressures were recorded from the first and third visits using an automated cuff. Patients in the control group were selected using the same criteria as above, and never seen by the pharmacist/nurse hypertension clinic. On average, each visit was at least two weeks apart, with the first and third visits being at least 4 weeks apart. Both groups had visits analyzed in the same time frame. Each visit was 30 min long, and patients were first educated by the registered nurse on lifestyle changes including the Dietary Approaches to Stop Hypertension (DASH) diet and exercise.8 The patients were then seen by the pharmacist who assessed compliance with their current medications, and assessed for any adverse drug reactions. Based on the patients' blood pressure at that visit, and their home blood pressure readings if available, the pharmacist was able to prescribe medications, including adjusting doses of their current antihypertensive medications, adding additional agents, or discontinuing medications at their discretion. The pharmacist was also able to order laboratory tests in order to monitor the side effects (serum creatinine, potassium) and efficacy of drug therapy. The control group included patients with uncontrolled hypertension that were not seen at the hypertension clinic. These patients saw their primary care providers who were either an attending physician, resident-in-training, nurse practitioner, or physician assistant. These patients were identified retrospectively through the electronic medical record system. Patients were selected sequentially through identifying patients whose blood pressure was not at goal and had 3 additional visits to their primary care provider, the first two being within 3 months to mirror the
experimental group. None of the patients followed any particular regimen or drug class to attain blood pressure control. Both groups utilized JNC-7 guidelines (current at that point in time) to guide therapy-based decisions. Adherence was assessed at every visit to both groups, but special importance was placed at visits in the experimental group with the pharmacist and registered nurse. The average reduction in systolic blood pressure, diastolic blood pressure and the status of blood pressure goal achievement were recorded. A Fisher's Exact test was performed to compare the goal blood pressure status of the experimental and control groups, with statistically significant values set at p < 0.05. Our goal was to determine if the interdisciplinary clinic showed any improvement in blood pressure control based on goal blood pressure achievement in our setting. The study was submitted to the Rochester Regional Health Instuitional Review Board for approval. 4. Results A total of 65 patients' blood pressures were evaluated, including 32 patients in the experimental group, and 33 from the control group. In the experimental group, the average systolic blood pressures dropped from 162 mmHg to 143 mmHg, and diastolic blood pressures dropped from 87 mmHg to 79 mmHg. In contrast, the control group's patients' average blood pressures dropped from 161 mmHg to 145 mmHg, and diastolic blood pressures dropped from 83 mmHg to 78 mmHg. The percentage of patients at their goal blood pressure was 59.4% in the experimental group, compared to 33.3% in the control group (p ¼ 0.048). (Fig. 1). Of note, 4 patients in the control group had the higher goal of 150/90 compared to 7 patients in the experimental group. 5. Discussion There is a mounting body of literature that supports the role of the pharmacist in interdisciplinary settings assisting in managing chronic disease states such as hypertension.5,6 With the shortage of physicians practicing in primary care and the influx of patients into the healthcare system, interdisciplinary teams working alongside physician counterparts will be needed to assist in providing quality care to patients. Pharmacists have the unique ability to discuss medication therapy at length with patients, which allow patients to more fully understand the treatment prescribed by their primary care provider. This affords the patients the knowledge that may give them more confidence in their medication regimen, leading to improving adherence. In addition, nurses have a very strong skill set in being able to provide education and resources to patients for not only lifestyle changes, but also assist with psycho-social situations that may be inhibiting the patients from achieving their healthcare
Table 1 Goal blood pressures. Qualifier
Goal Blood Pressure
Age <60 Age >60, no diabetes or kidney disease Age >60, diabetes or kidney disease
<140/<90 <150/<90 <140/<90
Fig. 1. Percentage of patients at goal.
A. DeLucenay et al. / Journal of Interprofessional Education & Practice 8 (2017) 57e59
goals. It should be noted that although the percentage drop in blood pressure in each group was relatively comparable, the goal achievement was higher in the experimental group. This is most likely due to the fact that the focus was specifically on hypertension, and the usual care group likely had many different ailments addressed at each visit with the primary care provider. Therefore, there was a very high importance placed on achieving a specific goal in the pharmacist/nurse group. 6. Limitations One of our limitations was the small sample size. The patient population was limited due to the fact that the clinic was relatively new, and did not yet have a large amount of patients. In addition, patients referred to the experimental group were generally seen as more difficult to obtain goal blood pressures. However, this gives credence to the pharmacist/nurse clinic as it can be perceived that these patients that had a more difficult time achieving their goal blood pressures were managed very effectively using the interdisciplinary approach. An additional limitation of our study was the lack of control for the change in blood pressure when comparing those at goal; we consider this study to provide preliminary evidence; however, further studies assessing change in blood pressure are needed. 7. Conclusion Interdisciplinary care with a nurse and pharmacist with collaborative drug therapy privileges leads to a statistically significant improvement in patients achieving goal blood pressure compared to standard of care. This adds to the body of literature demonstrating the value of pharmacists in interdisciplinary primary care. This is of utmost importance in today's healthcare environment where there are shortages of primary care healthcare providers and finite numbers of healthcare dollars. With the demonstration of the success of allied health providers in assisting in the care of patients alongside our physician colleagues, we are
59
able to further expand the role of these team members to work in collaboration to provide excellent patient care. As healthcare continues to move towards preventative care, pharmacists and nurses alike will be able to utilize their skill sets to improve patient outcomes. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of interest The Authors declare that there is no conflict of interest. References 1. Go AS, Mozaffarian D, Roger VL, et al. On behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics d2013 update: a report from the American Heart Association. Circulation. 2013;127:e6ee245. 2. Global Health Observatory (GHO) data. Raised blood pressure. Accessed April1 http://www.who.int/gho/ncd/risk_factors/blood_pressure_prevalence_text/en/; 2015. 3. Borenstein JE, Graber G, Saltiel E, et al. Physician- pharmacist comanagement of hypertension: a randomized, comparative trial. Pharmacotherapy. 2003;23(2): 209e216. 4. Vivian EM. Improving blood pressure control in pharmacist- managed hypertension clinic. Pharmacotherapy. 2002;22(12):1533e1540. 5. Santschi V, Chiolero A, Burnand B, et al. Impact of pharmacist care in the management of cardiovascular disease risk factors. Arch Intern Med. 2011;171(16):1441e1453. 6. Santschi V, Chiolero A, Colosimo AL, et al. Improving blood pressure control through pharmacist interventions: a meta-analysis of randomized controlled trials. J Am Heart Assoc. 2014;3. e000718. 7. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults. report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2013 Dec 18;311(5):508e520. 8. Description of the DASH Diet. National Heart Lung and Blood Institute; 2016, September. Retrieved from https://www.nhlbi.nih.gov/health/health-topics/ topics/dash/.