Posted on 10/01/08
JJ is a 70 year old patient with hypertension (HTN) and hyperlipidemia. He has difficulty remembering to take his blood pressure (BP) medication because his BP doesn't really bother him. He is a member of a local managed care plan. This HMO has a number of different care management, case management, and disease management programs, particularly for their older members. Some of the programs are coordinated by nurses, and some are coordinated by pharmacists. Is there any new literature on pharmacy case management programs, particularly in the cardiovascular realm?
New literature Supports the Use of Pharmacist Monitoring of Hypertension Control
Hypertension (HTN), defined as having a systolic BP (SBP) > 140 mm Hg and/or a diastolic BP (DBP) > 90 mm Hg, affected approximately 73 million Americans in 2005, and nearly 1 in 3 adults in the United States has HTN. It is the most common contributor to cardiovascular disease and its complications include stroke, myocardial infarction (MI), heart failure and kidney failure. HTN causes more than 1 million fatalities each year... it is sometimes called the "silent killer." Approximately 1 in 5 people in the workforce have HTN and along with associated complications, HTN accounts for 52 million days of lost work productivity annually. HTN is also the most common reason for physician office visits. yet despite these daunting statistics, many patients remain inadequately treated or controlled.
Recently, Green et al evaluated whether providing hypertensive patients access to members of their healthcare team online, along with home BP monitoring would improve BP control without in-person clinic visits. This was a 3-group, randomized, controlled trial known as the Electronic Communications and Home Blood Pressure Monitoring study, and was conducted at an integrated group practice in Washington State from June 2005 to December 2007. The study was based on the chronic care model and sought to determine whether HTN control was improved based on two different interventions: (1) home BP monitoring and training to use a patient web service; or (2) home BP monitoring and training to use a patient web service plus pharmacist care management delivered via the web. Both were compared to a control group receiving "usual care."
There were 778 patients enrolled of varying ages from 25 to 75 years. All patients had a diagnosis of uncontrolled essential HTN, were taking antihypertensive medication and had Internet access. Access for study was over a secure internet connection. Patients could not have diabetes, cardiovascular disease, renal disease or other serious conditions. Enrolled patients attended two screening visits, and those patients with SBP between 160 and 199 mm Hg were stratified into a separate subgroup to make sure even numbers were distributed in the three study groups. The primary outcomes were change in SBP and DBP and the percentage with controlled BP at 12 months (<140/90 mm Hg). Secondary outcomes included changes in the number of antihypertensive drug classes taken, aspirin use, body mass index (BMI), physical activity, health-related quality of life, satisfaction with the health plan, and use of health care services from baseline until the 12 month follow-up visit.
Patients assigned to active interventions were given a home BP monitor and trained in its proper use. They were told to check their BP at least twice a week on different days with two measurements each time. They were also trainined on how to use the web site. The group that was not using the pharmacist case management was told to work with their physician to improve their BP if it was not adequately controlled. They were allowed to contact their doctor via the web and e-mails daily. Other services of the web site are described in more detail in the article. The group that was using the pharmacist case management were assigned home BP monitoring and web training, plus were told that a pharmacist would assist them to improve their BP control via home BP monitoring and the web site. For the pharmacist case management patients, the pharmacist welcomed patients to the study with a secure message and informed the patient's physician of their study participation. The pharmacist also arranged for a one-time phone call with the patient to get a more detailed medication and cardiac history. After the call, the pharmacist introduced the patient to the action plan with lists of instructions and information for folllow-up. Each patient and their physician received a copy of the action plan. Planned communications occurred over the web every two weeks until BP was controlled, and less often thereafter. Three pharmacists at the health plan performed all the pharmacy interventions.
Of 778 patients enrolled, 730 (94%) completed the one-year follow-up visit. Patients who had only the home BP monitoring and web training had a nonsignificant increase in the percentage with controlled BP compared to those patients that had usual care (36% vs 31%, P=0.21). However, when web-based pharmacist care was added to home BP monitoring and web training, there was a significantly increased percentage of patients with controlled BP compared with the usual care patients (56% vs 31%, P<0.001) and home BP monitoring and web training only (56% vs 36%, P<0.001). SBP (adjusted mean change) was decreased in a stepwise manner from usual care (-5.3 mm Hg; range, -7.1 to -3.5), to home BP monitoring and web training only (-8.2 mm Hg; range, -10.0 to -6.4), to home BP monitoring and web training plus pharmacist care (-14.2; range, -16.0 to -12.4), with statistical significance of P<0.001. DBP was decreased only in the "pharmacist" group with an adjusted mean change of -7.0 mm Hg compared to both the usual care ( -3.5 mm Hg) and home BP/web training (-4.4 mm Hg); P<0.001. Compared with usual care, those patients that had a baseline SBP > 160 mm Hg and received home BP monitoring/web training and pharmacist care had a greater net reduction in SBP, DBP and improved BP control with 3.3-times more patients with BP control (P<0.001 for all parameters).
At baseline, patients took a mean of 1.6 HTN medication classes. At the 12 month follow-up, patients with web training only took 1.94 HTN medication classes, while usual care patients took 1.69 medication classes (P<0.01). Pharmacist managed patients took 2.16 medication classes, which was signficantly greater than the two other groups. Aspirin use significantly increased 1.3 -fold in the pharmacist care group compared to the usual care group and by 1.2 -fold relative to the group with web training only. Aspirin use did not significantly change in the other two groups. None of the other secondary outcomes were significantly different among the three intervention groups.
More pharmacist care managed patients had telephone encounters than the other two groups (7.5 vs 3.8 for web training [P<0.001] vs 4.0 in those with usual care [P<0.001] ). Primary care physician (PCP) visits did not differ between the three groups, nor did inpatient and urgent care or emergency department (ED) visits in the 12 month study. Two patients died of cancer-related complications in the web training group and one patient had a cardiac arrest in the pharmacist care group, but none of these were deemed to be study related.
This study showed that pharmacist care management delivered through a secure patient web communication system along with home BP monitoring improved BP control in patients with HTN without increasing PCP, ED, urgent care visits, or hospitalizations.
Back to the case:
If JJ's HMO has a HTN disease management program, he should enroll. This will help him with medication adherence and answer any disease and drug therapy related questions he may have. It will also likely assist him in controlling his BP so that he does not suffer from any of the adverse outcomes that are associated with uncontrolled HTN.
http://www.americanheart.org/downloadable/heart/1200082005246HS_Stats%202008.final.pdf Last accessed September 4, 2007
http://www.nathypertension.org/statistical%20data.html Last accessed September 4, 2007
Green BB, Cook AJ, Ralston JD et al. Effectiveness of home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control - A Randomized Controlled Trial. JAMA 2008;299(24):2857-2867.
Subscribe to RSS Feed
Mrs Hill, 57, has recently been diagnosed with hypertension. As she collects her regular medication, she asks to speak to the pharmacist about a side effect she is experiencing.
You take this as an opportunity to review Mrs Hill’s recent diagnosis and find out how she is coping. Below is an excerpt from her patient medication record.
Take one daily
Take one daily
Take one at night
Take one puff twice daily
Inhale two puffs four times a day when required
From the patient's records you can see she used 15 salbutamol inhalers in the last 12 months and has been prescribed four steroid inhalers in the same period.
The patient was using Seretide until four months ago, when she was changed to Sirdupla. Mrs Hill explains that she is "a bit confused" about why she had to change her inhaler, as she was "getting on fine before".
She was diagnosed six months ago with stage two hypertension – often referred to as severe high blood pressure. This is generally characterised by a systolic blood pressure value of greater than 159mmHg, or a diastolic blood pressure value of 99mmHg.
Mrs Hill was initiated on 5mg amlodipine, which was then increased to 10mg. Candesartan 8mg was consequently added to further improve her blood pressure.
The patient asks to have her blood pressure (BP) taken, and you find an average BP of 154/98. The patient’s serum cholesterol is 6.0mmol/L, and you calculate her BMI to be 27.4kg/m2. After speaking to Mrs Hill, you find out she is currently smoking 19 cigarettes a day and drinks four units of alcohol most days.
Mrs Hill says she has a busy and stressful job as a manager at a local restaurant. She has noticed some swelling in her legs, which began when she increased the dose of amlodipine.
Below is an excerpt from your medicines use review with Mrs Hill:
Advise Mrs Hill to speak to her GP urgently about leg swelling. This could be a symptom of another underlying problem, or that her medication is not appropriate.
For action by:
GP: Investigate the cause of oedema and rule out any underlying condition, such as heart failure.
Consider whether amlodipine dose should be reduced or stopped. Ankle swelling and oedema are commonly reported side effects of amlodipine.
Consider the addition of a thiazide-like diuretic – such as bendroflumethiazide – to reduce oedema and leg swelling.
Poor compliance with steroid inhaler.
Clarify the reason for the change of inhaler to the patient.
For action by:
Pharmacist: Explain to Mrs Hill that Sirdupla is the same as Seretide, but is a new branded generic available which is more cost effective to the NHS.
Discuss patient inhaler technique.
Patient: Ask Mrs Hill to bring in her inhaler the next time she is in, so she can show you how she uses her Sirdupla inhaler, and demonstrate how it works (if necessary). Explain to her that it works in the same way as her previous Seretide inhaler.
Mrs Hill's blood pressure is still high.
Ensure Mrs Hill is compliant with current therapy and whether the dosage is suitable.
For action by:
Patient: Ensure patient is compliant first. If she is, discuss lifestyle advice.
GP: Consider stepping up hypertension treatment or adding a thiazide-like diuretic.
The patient is overusing their reliever inhaler.
A patient using 15 or more reliever inhalers per year is likely to have poorly controlled asthma.
For action by:
Patient: advise patient of the difference between reliever and preventer inhalers and ensure patient is using them appropriately.
Pharmacist: Ensure patient is using their inhaler appropriately.
GP: if asthma is still uncontrolled when a patient is compliant with therapy, consider stepping up therapy to step four of British thoracic society’s guidelines.
Encourage patient to consider current lifestyle advice – including losing weight and stopping smoking – to reduce cardiovascular risk score.
For action by:
Patient and pharmacist:
- You should recommend Mrs Hill tries to lose weight, and direct her to current sources of healthy eating advice.
- Encourage Mrs Hill to improve her exercise regime. Explain that it is currently recommended to partake in 30 minutes of moderate intensity exercise five times per week. This can be easily achieved by making small changes, for example walking to work or joining a local walking group.
- Reduce caffeine intake, as this increases blood pressure.
- Advise her to sign up to a local stop smoking scheme, either in the pharmacy or through her GP. Explain that these have been proven to be much more effective than attempting to quit alone. Read the CPD module Supporting smokers to quit to find out more.
- Consider reducing alcohol intake. This will contribute to reducing blood pressure and has wider health benefits. Explain that in order to keep health risks from alcohol at a low level, no more than 14 units should be drunk over the course of a week – spread evenly over three or more days – and advise that she has several alcohol-free days each week.
Relaxation therapies can help to reduce blood pressure, and Mrs Hill may wish to consider this option alongside her current treatment regimen.
After the MUR you agree with Mrs Hill to see her next week to discuss the use of her inhalers. You also make a note in the patient medication record to follow up on the outcome of her leg oedema.