The benefits of physician-pharmacist collaboration

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Applied Evidence

The benefits of physician-pharmacist collaboration

J Fam Pract. 2017 December;66(12):E1-E8

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References

1. Borenstein JE, Graber G, Saltiel E, et al. Physician-pharmacist comanagement of hypertension: a randomized, comparative trial. Pharmacotherapy. 2003;23:209-216.

2. Hunt JS, Siemienczuk J, Pape G, et al. A randomized controlled trial of team-based care: impact of physician-pharmacist collaboration on uncontrolled hypertension. J Gen Intern Med. 2008;23:1966-1972.

3. Carter BL, Bergus GR, Dawson JD, et al. A cluster randomized trial to evaluate physician/pharmacist collaboration to improve blood pressure control. J Clin Hypertens (Greenwich). 2008;10:260-271.

4. Carter BL, Ardery G, Dawson JD, et al. Physician and pharmacist collaboration to improve blood pressure control. Arch Intern Med. 2009;169:1996-2002.

5. Weber CA, Ernst ME, Sezate GS, et al. Pharmacist-physician comanagement of hypertension and reduction in 24-hour ambulatory blood pressures. Arch Intern Med. 2010;170:1634-1639.

6. Hirsch JD, Steers N, Adler DS, et al. Primary care-based, pharmacist-physician collaborative medication-therapy management of hypertension: a randomized, pragmatic trial. Clin Ther. 2014;36:1244-1254.

7. Carter BL, Coffey CS, Ardery G, et al. Cluster-randomized trial of a physician/pharmacist collaborative model to improve blood pressure control. Circ Cardiovasc Qual Outcomes. 2015;8:235-243.

8. Sisson EM, Dixon DL, Kildow DC, et al. Effectiveness of a pharmacist-physician team-based collaboration to improve long-term blood pressure control at an inner-city safety-net clinic. Pharmacotherapy. 2016;36:342-347.

9. Kiel PJ, McCord AD. Pharmacist impact on clinical outcomes in a diabetes disease management program via collaborative practice. Ann Pharmacother. 2005;39:1828-1832.

10. Farland MZ, Byrd DC, McFarland MS, et al. Pharmacist-physician collaboration for diabetes care: the diabetes initiative program. Ann Pharmacother. 2013;47:781-789.

11. Howard-Thompson A, Farland MZ, Byrd DC, et al. Pharmacist-physician collaboration for diabetes care: cardiovascular outcomes. Ann Pharmacother. 2013;47:1471-1477.

12. Gums TH, Carter BL, Milavetz G, et al. Physician-pharmacist collaborative management of asthma in primary care. Pharmacotherapy. 2014;34:1033-1042.

13. Greer N, Bolduc J, Geurkink E, et al. VA Evidence-based Synthesis Program Reports. Pharmacist-Led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared to Usual Care. Washington (DC): Department of Veterans Affairs (US); 2015.

14. Wentzlaff DM, Carter BL, Ardery G, et al. Sustained blood pressure control following discontinuation of a pharmacist intervention. J Clin Hypertens (Greenwich). 2011;13:431-437.

15. Carter BL, Vander Weg MW, Parker CP, et al. Sustained blood pressure control following discontinuation of a pharmacist intervention for veterans. J Clin Hypertens (Greenwich). 2015;17:701-708.

16. Kulchaitanaroaj P, Brooks JM, Ardery G, et al. Incremental costs associated with physician and pharmacist collaboration to improve blood pressure control. Pharmacotherapy. 2012;32:772-780.

17. Polgreen LA, Han J, Carter BL, et al. Cost effectiveness of a physician-pharmacist collaboration intervention to improve blood pressure control. Hypertension. 2015;66:1145-1151.

18. Carter BL. Primary care physician-pharmacist collaborative care model: strategies for implementation. Pharmacotherapy. 2016;36:363-373.

19. Anderegg MD, Gums TH, Uribe L, et al. Physician-pharmacist collaborative management: narrowing the socioeconomic blood pressure gap. Hypertension. 2016;68:1314-1320.

20. Moczygemba LR, Goode JV, Gatewood SBS, et al. Integration of collaborative medication therapy management in a safety net patient-centered medical home. J Am Pharm Assoc (2003). 2011;51:167-172.

21. Scott MA, Hitch B, Ray L, et al. Integration of pharmacists into a patient-centered medical home. J Am Pharm Assoc (2003). 2011;51:161-166.

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PPCM leads to greater BP reductions, improved BP control

The majority of research surrounding PPCM has focused on uncontrolled HTN.^1-8 Patients in many of these studies saw a pharmacist in a specialized HTN clinic, where the multidisciplinary staff performed a thorough evaluation of the patient’s current hypertensive management. The pharmacists in these PPCM programs closely monitored patients and made adjustments to antihypertensive regimens as necessary. Systolic and diastolic BP reductions in the intervention groups ranged from 14 to 36 mm Hg and 7 to 15 mm Hg, respectively.^1-5,7,8 The percentage of patients with BP control at the end of the studies ranged from 43% to 89%.^1,3,4,6,7

In a prospective, cluster-randomized trial performed at 32 primary care offices in 15 states, researchers assigned 625 patients with uncontrolled HTN to receive physician-pharmacist collaborative care or usual care with primary care provider management.⁷ As part of the PPCM intervention, clinical pharmacists conducted a thorough medical record review and a structured interview of the patients. During the interview, the clinical pharmacists reviewed the patient’s medication history, assessed the patient’s knowledge of BP medications, and addressed any barriers to adherence. In collaboration with the physician, the pharmacists developed a care plan with recommendations for optimizing the drug regimen. After the baseline visit, the pharmacists conducted structured face-to-face interviews with patients at 1, 2, 4, 6, and 8 months, with additional visits scheduled if BP was still uncontrolled.

At 9 months, patients in the PPCM group had significantly greater reductions in BP than those in the control group, and BP control was achieved in 43% of the PPCM group vs 34% of the control group. This study corroborates results from previous (similar) studies investigating the impact of PPCM on patients with uncontrolled HTN.^1-6

PPCM helps patients reduce their HbA1c levels

Researchers have also studied the impact of PPCM strategies on the management of diabetes mellitus.^9-11 In one retrospective study of 157 patients, implementation of a pharmacy-coordinated diabetes (any type) management program significantly improved HbA1c and increased the percentage of patients reaching their HbA1c goal.⁹ Furthermore, researchers observed improvements in low-density lipoprotein cholesterol (LDL-C) levels and an increased number of patients obtaining a microalbumin screening after initiation of the program.

A more recent prospective, multicenter cohort study of 206 patients with uncontrolled type 2 diabetes had similar results.¹⁰ In collaboration with the primary care physician (PCP), clinical pharmacists provided medication therapy management through adjustment of antihyperglycemic, antihypertensive, or lipid-lowering medications. Additional interventions provided by the pharmacists included reviewing blood glucose logs, ordering and monitoring laboratory tests, performing sensory foot examinations, and providing patient education.

Implementation of PPCM reduced the average HbA1c by 1.2% and increased the percentage of patients achieving an HbA1c <7% by about 24%. The researchers also observed improvements in BP and LDL-C levels in this patient population.¹¹

Asthma and beyond

Future studies may well show that the benefits of PPCM extend to the management of other chronic diseases. One prospective, pre-post study of 126 patients with asthma found that the number of emergency department (ED) visits and/or hospitalizations decreased 30% during 9 months with a PPCM intervention and then returned to levels similar to baseline once the intervention ceased.¹² Other potential disease areas that have been studied, or are being studied, include chronic obstructive pulmonary disease, chronic kidney disease, dyslipidemia, and congestive heart failure.¹³

Benefits derive from altered health care utilization

Researchers attribute much of the benefit observed with PPCM to the increased—albeit different—health-care utilization among the patients in the intervention groups. In general, patients participating in PPCM have an increased total number of visits, but more of those visits are with pharmacists and fewer are with physicians; they also are prescribed more medications, but don’t necessarily take more pills per day.^1,2,5In the end, patients have been found to achieve significantly better disease control without compromising quality of life or satisfaction.²

Some studies have found that continued pharmacist involvement may be necessary to sustain the benefits achieved.⁶ However, other studies have suggested that the benefits are maintained even after discontinuation of the pharmacist intervention.^14,15 Thus, further research is necessary to determine which patients may benefit most from ongoing involvement with a pharmacist.

How cost-effective is the PPCM model?

Implementing a PPCM model in a primary care setting often hinges upon whether the intervention will be cost-effective. Several studies have reported the cost-effectiveness of clinical pharmacists in the management of HTN.^1,16,17

Borenstein and colleagues found significantly lower provider visit costs per patient in the PPCM group ($160) compared with the usual care group ($195), a difference that the authors attributed to a decreased number of visits to PCPs and an increased number of lower cost visits with pharmacists in the PPCM group.¹ However, the difference could have been affected by the arbitrary measurement of physician-pharmacist collaboration time in the study.