COMMENTARY
Will Team-Based Care Really Be Implemented? Barry L. Carter, PharmD1,2 From the Department of Pharmacy Practice and Science, College of Pharmacy;1 and Department of Family Medicine, College of Medicine, University of Iowa, Iowa City, IA2
Team-based care is an effective strategy to improve blood pressure (BP) in primary care.1,2 The most recent meta-analysis evaluated 39 randomized controlled trials in 14,224 patients and found that pharmacist interventions reduced systolic BP by 7.6 mm Hg (95% confidence interval, 9.0 mm Hg to 6.3 mm Hg) compared with usual care.3 The authors concluded that pharmacist interventions were highly effective but that additional studies are still needed to determine the most efficient methods of implementation.3 Nearly all previous studies were efficacy studies conducted under optimal conditions. The National Heart, Lung, and Blood Institute has committed extensive funding to evaluate whether interventions known to be effective in efficacy studies conducted under optimal conditions will be implemented in usual care scenarios. We recently completed such an implementation trial in 32 medical offices throughout the United States and found that the pharmacist intervention reduced systolic BP by 6 mm Hg in all patients including underrepresented minorities.4 However, as with most previous studies, this trial recruited patients willing to participate and obtained research BP measurements for 2 years. What we don’t know from previous studies is how physicians would respond to requests to have pharmacists manage patients with uncontrolled hypertension identified from electronic medical record (EMR) reports. Such information has important implications as care is being transitioned to the patient-centered medical home (PCMH) and payment structures that include per member per month and incentive-based pay that eliminate prior fee for service systems.5,6 Health systems, clinics, and physicians are now tasked with providing the most efficient utilization of team personnel to optimize patient outcomes including high BP control rates. In this issue of The Journal of Clinical Hypertension, Smith and colleagues7 evaluated physician acceptance of a physician-pharmacist collaborative model in two internal medicine offices. The model was developed with collaboration and input from the physician leadership from the offices. The investigators identified 1516 patients with uncontrolled hypertension who met the inclusion criteria from two internal medicine clinics. Physicians could approve or deny any request for the
Address for correspondence: Barry L. Carter, PharmD, Department of Pharmacy Practice and Science, Room 527, College of Pharmacy, University of Iowa, Iowa City, IA 52242 E-mail: [email protected] DOI: 10.1111/jch.12578
692
The Journal of Clinical Hypertension
Vol 17 | No 9 | September 2015
pharmacist to assist with patient management and 10.6% of requests had no response. The majority (58%) of physicians were residents. Physicians approved 70.1% of the requests, which may seem low compared with studies that have found that physicians accepted 96% to 98% of pharmacist recommendations.4,8 However, the issues are different between these studies. These previous studies evaluated specific drug therapy modification recommendations in carefully selected patients who met extensive inclusion criteria after the physician already approved the patients’ participation. The study by Smith and colleagues requested a referral to a pharmacist to manage therapy for all patients with poor BP control. Most of the refusals were related to the physician wanting to manage the patient (19%), the physician felt the BP was controlled (18%), or the patient was unable to make appointments (12%). These patients would likely have been excluded from previous studies. It is impossible to know why physicians wanted to manage some patients themselves. Some of these refusals may have been residents who simply wanted experience adjusting BP medications. It might be questioned whether the 18% of refusals when the physician felt the BP was controlled is appropriate even after the chart indicated BP was not controlled. However, the investigators used the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines and physicians were likely aware of evolving data supporting higher BP goals especially for the elderly or patients with diabetes or chronic kidney disease.9 It appears that many of the physician refusals may have been for patients with complex psychosocial issues (eg, unable to make appointments, too complex) or the physician still needed to develop a stronger patient relationship (patient too new). If these suppositions are correct, these physician refusals are understandable and appropriate. What does the study by Smith and colleagues add to the large body of literature already available showing physician-pharmacists collaborative interventions improve BP control? This study demonstrates that a large percentage of patients (70%) with uncontrolled hypertension identified from EMR lists would receive physician approval for referral to a pharmacist-management model. Usually, the patients who remain uncontrolled are that subset of the medical office population with hypertension (often 20%–40%) who have had uncontrolled BP for many years, have adherence problems, or have unique pharmacotherapy needs. The information from this study is important for
Commentary
physicians and leadership in health systems and medical offices who are striving to achieve incremental improvements in BP control in order to achieve pay for performance or other financial incentives. The strategy used to identify potential patients from the EMR is an optimal way to conduct population-based strategies to improve BP control. This study also provides important information concerning potential patients who may not be ideal for a pharmacist-managed program. A strength of the study by Smith and colleagues is the approach to determine why physicians chose to decline a request for referral. Physicians are in the best position to assess psychosocial or other issues that might make referral to the collaborative program disruptive to continuity or the physician-patient relationship. One way to deal with such issues might be to have the physician and pharmacist see the patient together to reduce patient reluctance, yet still allow recommendations to the physician to be made by the pharmacist. If some residents were denying referral because they wanted to learn from the experience of managing hypertension, seeing the patients together can be a strong educational opportunity to learn pharmacotherapy strategies from the clinical pharmacist.10 The concept of the PCMH emphasizes that care be organized around the needs of the patient and the relationship with their personal physician.5,6 The physician-led teams may form and reform according to the needs of the patient, similar to the study by Smith and colleagues7 Within the PCMH and the physician-pharmacist collaborative models, the physician delegates responsibility to pharmacists to perform a medication history, identify problems and barriers to achieving disease control, perform counseling on lifestyle modification, and adjust medications following hypertension guidelines.4,8 This approach allows the physician to address more acute problems and complications. There is evidence that the PCMH improves healthcare delivery outcomes, increases physician satisfaction, and decreases the costs of care.11,12
The study by Smith and colleagues and other studies have focused on the physician-pharmacist collaborative model. Major changes are occurring within healthcare delivery and financing. More research is needed to determine the most efficient strategies for not only these providers but also other members of the healthcare team including nurses, dieticians, social workers, and receptionist staff. Acknowledgment: Dr Carter is supported by National Heart, Lung, and Blood Institute grants R01HL116311 and R18HL116259.
References 1. Carter BL, Bosworth HB, Green BB. The hypertension team: the role of the pharmacist, nurse, and teamwork in hypertension therapy. J Clin Hypertens (Greenwich). 2012;14:51–65. 2. Carter BL, Rogers M, Daly J, et al. The potency of team-based care interventions for hypertension: a meta-analysis. Arch Intern Med. 2009;169:1748–1755. 3. 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. 4. Carter BL, Coffey CS, Ardery G, et al. A cluster-randomized trial of a physician-pharmacist collaborative model to improve blood pressure control. Circ Cardiovasc Qual Outcomes 2015; doi:10.1161/CIRC OUTCOMES.114.001283. 5. Rosenthal TC. Advancing Medical Homes: evidence-based literature review to inform health policy. http://www.ahec.buffalo.edu. Accessed May 8, 2015. 6. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291:1246–1251. 7. Smith SM, Hasan M, Huebschmann AG, et al. Physician acceptance of a physician-pharmacist collaborative treatment model for hypertension management in primary care. J Clin Hypertens (Greenwich). 2015; DOI: 10.1111/jch.12575. 8. 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. 9. 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. 2014;311:507–520. 10. Carter BL, Zillich AJ, Elliott WJ. How pharmacists can assist physicians with controlling blood pressure. J Clin Hypertens (Greenwich). 2003;5:31–37. 11. Reid RJ, Coleman K, Johnson EA, et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29:835–843. 12. Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009;15:e71–e87.
The Journal of Clinical Hypertension
Vol 17 | No 9 | September 2015
693
Will Team-Based Care Really Be Implemented? Barry L. Carter, PharmD1,2 From the Department of Pharmacy Practice and Science, College of Pharmacy;1 and Department of Family Medicine, College of Medicine, University of Iowa, Iowa City, IA2
Team-based care is an effective strategy to improve blood pressure (BP) in primary care.1,2 The most recent meta-analysis evaluated 39 randomized controlled trials in 14,224 patients and found that pharmacist interventions reduced systolic BP by 7.6 mm Hg (95% confidence interval, 9.0 mm Hg to 6.3 mm Hg) compared with usual care.3 The authors concluded that pharmacist interventions were highly effective but that additional studies are still needed to determine the most efficient methods of implementation.3 Nearly all previous studies were efficacy studies conducted under optimal conditions. The National Heart, Lung, and Blood Institute has committed extensive funding to evaluate whether interventions known to be effective in efficacy studies conducted under optimal conditions will be implemented in usual care scenarios. We recently completed such an implementation trial in 32 medical offices throughout the United States and found that the pharmacist intervention reduced systolic BP by 6 mm Hg in all patients including underrepresented minorities.4 However, as with most previous studies, this trial recruited patients willing to participate and obtained research BP measurements for 2 years. What we don’t know from previous studies is how physicians would respond to requests to have pharmacists manage patients with uncontrolled hypertension identified from electronic medical record (EMR) reports. Such information has important implications as care is being transitioned to the patient-centered medical home (PCMH) and payment structures that include per member per month and incentive-based pay that eliminate prior fee for service systems.5,6 Health systems, clinics, and physicians are now tasked with providing the most efficient utilization of team personnel to optimize patient outcomes including high BP control rates. In this issue of The Journal of Clinical Hypertension, Smith and colleagues7 evaluated physician acceptance of a physician-pharmacist collaborative model in two internal medicine offices. The model was developed with collaboration and input from the physician leadership from the offices. The investigators identified 1516 patients with uncontrolled hypertension who met the inclusion criteria from two internal medicine clinics. Physicians could approve or deny any request for the
Address for correspondence: Barry L. Carter, PharmD, Department of Pharmacy Practice and Science, Room 527, College of Pharmacy, University of Iowa, Iowa City, IA 52242 E-mail: [email protected] DOI: 10.1111/jch.12578
692
The Journal of Clinical Hypertension
Vol 17 | No 9 | September 2015
pharmacist to assist with patient management and 10.6% of requests had no response. The majority (58%) of physicians were residents. Physicians approved 70.1% of the requests, which may seem low compared with studies that have found that physicians accepted 96% to 98% of pharmacist recommendations.4,8 However, the issues are different between these studies. These previous studies evaluated specific drug therapy modification recommendations in carefully selected patients who met extensive inclusion criteria after the physician already approved the patients’ participation. The study by Smith and colleagues requested a referral to a pharmacist to manage therapy for all patients with poor BP control. Most of the refusals were related to the physician wanting to manage the patient (19%), the physician felt the BP was controlled (18%), or the patient was unable to make appointments (12%). These patients would likely have been excluded from previous studies. It is impossible to know why physicians wanted to manage some patients themselves. Some of these refusals may have been residents who simply wanted experience adjusting BP medications. It might be questioned whether the 18% of refusals when the physician felt the BP was controlled is appropriate even after the chart indicated BP was not controlled. However, the investigators used the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines and physicians were likely aware of evolving data supporting higher BP goals especially for the elderly or patients with diabetes or chronic kidney disease.9 It appears that many of the physician refusals may have been for patients with complex psychosocial issues (eg, unable to make appointments, too complex) or the physician still needed to develop a stronger patient relationship (patient too new). If these suppositions are correct, these physician refusals are understandable and appropriate. What does the study by Smith and colleagues add to the large body of literature already available showing physician-pharmacists collaborative interventions improve BP control? This study demonstrates that a large percentage of patients (70%) with uncontrolled hypertension identified from EMR lists would receive physician approval for referral to a pharmacist-management model. Usually, the patients who remain uncontrolled are that subset of the medical office population with hypertension (often 20%–40%) who have had uncontrolled BP for many years, have adherence problems, or have unique pharmacotherapy needs. The information from this study is important for
Commentary
physicians and leadership in health systems and medical offices who are striving to achieve incremental improvements in BP control in order to achieve pay for performance or other financial incentives. The strategy used to identify potential patients from the EMR is an optimal way to conduct population-based strategies to improve BP control. This study also provides important information concerning potential patients who may not be ideal for a pharmacist-managed program. A strength of the study by Smith and colleagues is the approach to determine why physicians chose to decline a request for referral. Physicians are in the best position to assess psychosocial or other issues that might make referral to the collaborative program disruptive to continuity or the physician-patient relationship. One way to deal with such issues might be to have the physician and pharmacist see the patient together to reduce patient reluctance, yet still allow recommendations to the physician to be made by the pharmacist. If some residents were denying referral because they wanted to learn from the experience of managing hypertension, seeing the patients together can be a strong educational opportunity to learn pharmacotherapy strategies from the clinical pharmacist.10 The concept of the PCMH emphasizes that care be organized around the needs of the patient and the relationship with their personal physician.5,6 The physician-led teams may form and reform according to the needs of the patient, similar to the study by Smith and colleagues7 Within the PCMH and the physician-pharmacist collaborative models, the physician delegates responsibility to pharmacists to perform a medication history, identify problems and barriers to achieving disease control, perform counseling on lifestyle modification, and adjust medications following hypertension guidelines.4,8 This approach allows the physician to address more acute problems and complications. There is evidence that the PCMH improves healthcare delivery outcomes, increases physician satisfaction, and decreases the costs of care.11,12
The study by Smith and colleagues and other studies have focused on the physician-pharmacist collaborative model. Major changes are occurring within healthcare delivery and financing. More research is needed to determine the most efficient strategies for not only these providers but also other members of the healthcare team including nurses, dieticians, social workers, and receptionist staff. Acknowledgment: Dr Carter is supported by National Heart, Lung, and Blood Institute grants R01HL116311 and R18HL116259.
References 1. Carter BL, Bosworth HB, Green BB. The hypertension team: the role of the pharmacist, nurse, and teamwork in hypertension therapy. J Clin Hypertens (Greenwich). 2012;14:51–65. 2. Carter BL, Rogers M, Daly J, et al. The potency of team-based care interventions for hypertension: a meta-analysis. Arch Intern Med. 2009;169:1748–1755. 3. 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. 4. Carter BL, Coffey CS, Ardery G, et al. A cluster-randomized trial of a physician-pharmacist collaborative model to improve blood pressure control. Circ Cardiovasc Qual Outcomes 2015; doi:10.1161/CIRC OUTCOMES.114.001283. 5. Rosenthal TC. Advancing Medical Homes: evidence-based literature review to inform health policy. http://www.ahec.buffalo.edu. Accessed May 8, 2015. 6. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291:1246–1251. 7. Smith SM, Hasan M, Huebschmann AG, et al. Physician acceptance of a physician-pharmacist collaborative treatment model for hypertension management in primary care. J Clin Hypertens (Greenwich). 2015; DOI: 10.1111/jch.12575. 8. 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. 9. 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. 2014;311:507–520. 10. Carter BL, Zillich AJ, Elliott WJ. How pharmacists can assist physicians with controlling blood pressure. J Clin Hypertens (Greenwich). 2003;5:31–37. 11. Reid RJ, Coleman K, Johnson EA, et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29:835–843. 12. Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009;15:e71–e87.
The Journal of Clinical Hypertension
Vol 17 | No 9 | September 2015
693
