NEW YORK – When it comes to getting hypertensive patients to take their medications and to achieve improvements in their blood pressures, it takes a village – or at least a really motivated pharmacist, according to Barry Carter, Pharm. D.
“Team-based care interventions are one of the most potent strategies to achieve blood pressure control, even for those patients with difficult-to-control blood pressure,” said Dr. Carter, professor and associate head for research in the department of family medicine at the University of Iowa, Iowa City. “While improving adherence is one key reason for the success,” it's also important to step-up the intensity of the medical management by increasing the number of patient encounters and the intensity of blood pressure monitoring. It's “one of the most important strategies we've seen” to help overcome “clinical inertia.”
In a 2009 systematic review of controlled clinical trials, Dr. Carter and associates showed the potency of using pharmacists and nurses in hypertension management. In studies in which the pharmacist made recommendations to the physician, there was an average reduction of 9.3 mm Hg in systolic BP, compared with settings that did not use team-based care (Arch. Intern. Med. 2009;169:1748-55).
By comparison, in studies in which the nurse did the intervention, the reduction in systolic blood pressure was 4.8 mm Hg greater than in the non–team-based care. Both results were statistically significant, he said at the meeting. (See graph.)
Home-based blood pressure monitoring in other studies and systematic reviews showed an average blood pressure reduction of 2.4 mm Hg, according to Dr. Carter. “When added to team-based care, home-based blood pressure monitoring is much more effective than home monitoring alone,” he said.
Dr. Carter also commented on preliminary results from HINTS (Hypertension Intervention Nurse Telemedicine Study). This Veterans Affairs study involved four arms: a control group that received usual care, nurse-administered behavioral intervention, nurse-administered medication management, and a combination of the nurse-administered behavioral and medical management interventions.
“The proportion achieving blood pressure control at 12 months started out around 59%, and in the intervention groups it was near 70%,” Dr. Carter said. But by 18 months, the between-group differences had tapered off (Am. Heart J. 2009;157:450-6). A limitation of the study is that about half the patients had uncontrolled blood pressure when they entered the trial. “There was a statistically significant improvement in the odds ratio of blood pressure being controlled with nurse management,” Dr. Carter added.
A 2008 study of 778 patients showed that adding Web-based pharmacist care to a protocol of home blood pressure monitoring and Web training significantly increased the percentage of patients with controlled blood pressure (JAMA 2008;299: 2857-67).
At baseline, all patients had systolic BPs in the low 150–mm Hg range, he said. After 12 months, the usual-care arm had an average reduction in systolic blood pressure of 5 mm Hg, and the arm with home blood pressure monitoring and patient interaction via the Web showed an average reduction of 8 mm Hg. By contrast, the group that received home-based monitoring and Web-based assistance by the pharmacist had an average reduction in systolic blood pressure of 14 mm Hg, he said.
Reimbursement issues are among the most significant barriers to a team-based approach for hypertension management, Dr. Carter acknowledged. “The business model has really been a critical problem,” he said. “The reason the Kaiser-Permanentes, Group Health, and the VAs can do this is because they don't operate on a fee-for-service model.” Although Medicare Part D allows for team-based management of hypertension, Medicare itself has not yet completed a relative-value unit for the service, he said.
Dr. Carter is currently leading the CAPTION (Collaboration Among Pharmacists and Physicians to Improve Outcomes Now) trial, the purpose of which is to determine if the face-to-face physician-pharmacist collaborative model will be adopted in typical practice settings, funded by the National Institutes of Health.
Dr. Carter had no relevant conflicts of interest.
'When added to team-based care, home-based [BP] monitoring is much more effective than home monitoring alone.'
Source Elsevier Global Medical News