Implementation and evaluation of a pharmacist-led hypertension management service in primary care: outcomes and methodological challenges

ORIGINAL RESEARCH   Implementation and evaluation of a pharmacist-led hypertension management service in primary care: outcomes and methodological challenges     Beata Bajorek1, Kate S. Lemay2, Parker Magin3, Christopher Roberts4, Ines Krass5 and Carol L. Armour6 1 PhD BPharm DipHospPharm GradCertEdStud(HigherEd). Academic Pharmacist and Associate Professor. Graduate School of Health - Pharmacy, University of Technology Sydney. Broadway, NSW (Australia). 2 BPharm MA. Project Manager. Woolcock Institute of Medical Research, University of Sydney. Glebe, NSW (Australia). 3 MBBS PhD MFM MGPP DPD GDipClinEpi FRACGP. Academic General Practitioner and Conjoint Professor, Discipline of General Practice, University of Newcastle. Callaghan, NSW (Australia). 4 MbCh, DRCOG MMEDSCI MRCGP FRACGP PhD. Associate Professor in Primary Care and Medical Education. Sydney Medical School - Northern, Hornsby Ku-ring-Gai Hospital. Hornsby, NSW (Australia). 5 BPharm DipHospPharm GradDipEdStudies (Health Ed) PhD. Professor of Pharmacy Practice. Faculty of Pharmacy, University of Sydney. Sydney, NSW (Australia). 6 BPharm(Hons) PhD. Professor of Pharmacology and Executive Director Woolcock Institute of Medical Research, University of Sydney and Sydney Local Health District, Woolcock Institute of Medical Research, University of Sydney. Glebe, NSW (Australia). This study received funding from the National Heart Foundation (Australia).     ABSTRACT Background: Suboptimal utilisation of pharmacotherapy, non-adherence to prescribed treatment, and a lack of monitoring all contribute to poor blood (BP) pressure control in patients with hypertension. Objective: The objective of this study was to evaluate the implementation of a pharmacist-led hypertension management service in terms of processes, outcomes, and methodological challenges. Method: A prospective, controlled study was undertaken within the Australian primary care setting. Community pharmacists were recruited to one of three study groups: Group A (Control - usual care), Group B (Intervention), or Group C (Short Intervention). Pharmacists in Groups B and C delivered a service comprising screening and monitoring of BP, as well as addressing poor BP control through therapeutic adjustment and adherence strategies. Pharmacists in Group C delivered the shortened version of the service. Results: Significant changes to key outcome measures were observed in Group C: reduction in systolic and diastolic BPs at the 3-month visit (P<0.01 and P<0.01, respectively), improvement in medication adherence scores (P=0.01), and a slight improvement in quality of life (EQ-5D-3L Index) scores (P=0.91). There were no significant changes in Group B (the full intervention), and no differences in comparison to Group A (usual care). Pharmacists fed-back that patient recruitment was a key barrier to service implementation, highlighting the methodological implications of screening. Conclusion: A collaborative, pharmacist-led hypertension management service can help monitor BP, improve medication adherence, and optimise therapy in a step-wise approach. However, blood pressure screening can effect behaviour change in patients, presenting methodological challenges in the evaluation of services in this context. Key words: Hypertension; Community Pharmacy Services; Interprofessional Relations; Medication Adherence; Medication Therapy Management; Methodology; Australia.   Introduction There is a need for targeted services in chronic disease management, particularly in hypertension where up to 67.5% of people are reported to have inadequate blood pressure (BP) control.1 Clinical inertia, non-adherence by patients, and a lack of monitoring underpin poor BP control.2-4 Here, an opportunity exists for a multi-faceted, collaborative approach involving the community pharmacist and GP to optimise hypertension management.5 In the Australian primary care setting, a number of studies have shown that pharmacist-led interventions can rationalise medicines use in patients6,7, improve clinicians' prescribing of evidence-based therapies in cardiovascular disease7-9, and improve patient self-management as well as clinical outcomes.10,11 In regard to the management of hypertension, previous studies have demonstrated the positive impact that pharmacists can have on a range of outcomes. Even dating back to the 1990s, studies have shown that community pharmacist-led services comprising patient education and blood pressure monitoring (including the use home blood pressure readings obtained from monitors that wirelessly transmit information to the pharmacy) can improve patient knowledge about hypertension, significantly decrease mean blood pressure, improve blood pressure control in those not at treatment targets, and rationalise the use of antihypertensive medication.12-15 A Cochrane review also reports the positive outcomes from pharmacist-led care, with the majority of controlled trials associated with improved blood pressure control.16 Even those studies that have focused on patient self-management (e.g., self-monitoring of BP) have shown that additional support from health professionals may enhance the BP lowering effect of any intervention.17 Pharmacy practice has, of course, evolved in recent times, comprising more specialised roles and an expanded scope of practice. This has been highlighted by the RxACTION trial (i.e., the Rural Alberta Clinical Trial in Optimizing Hypertension).18 which evaluated the impact of enhanced pharmacist care on the management of patients with hypertension; this enhanced care involved pharmacists taking a more active role and independently prescribing antihypertensive medication. The study showed that the enhanced care resulted in significantly larger reductions in both systolic and diastolic blood pressure, with patients twice as likely to reach their recommended blood-pressure targets, compared to usual care. Although this type of expanded care is not yet legislated in Australia, pilot studies have also demonstrated the potential for pharmacist prescribing in hypertension management, suggesting that credentialed pharmacists are able to make appropriate therapeutic decisions.19 In delivering such interventions, it is important to recognise that the management of hypertension is relatively complex, comprising screening and monitoring of blood pressure, addressing adherence barriers, and reviewing pharmacotherapy.20,21 It is these aspects of hypertension management that Australian community pharmacists need to currently focus on, in preparation for future expanded care services.22,23 Therefore, the aim of this paper is to report on the lessons learned from a pilot study of a pharmacist-led intervention (hypertension management service) in Australian primary care. Specifically, the objectives of this paper are to: 1) describe the key outcomes following delivery of the intervention; 2) report pharmacists' feedbac (...truncated)