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Evaluation of Pharmacist Care for Hypertension in the Veterans Affairs Patient-centered Medical Home: A Retrospective Case-control Study

Published:December 19, 2014DOI:https://doi.org/10.1016/j.amjmed.2014.11.027

      Abstract

      Objective

      The study objective was to evaluate a pharmacist hypertension care management program within the patient-centered medical home.

      Methods

      This was a retrospective case-control study. Cases included all patients with hypertension who were referred to the care management program, and controls included patients with hypertension who were not referred to the program during the same 1-year period. Each case was matched to a maximum of 3 controls on the basis of primary care physician, age ±5 years, gender, diagnoses of diabetes and kidney disease, baseline systolic blood pressure ±10 mm Hg, and number of unique antihypertensive medications. Pharmacists provided a hypertension care management program under an approved scope of practice that allowed pharmacists to meet individually with patients, adjust medications, and provide patient education. Primary outcomes were systolic blood pressure and diastolic blood pressure at 6 and 12 months. Multivariate regression models compared each blood pressure end point between cases and controls adjusting for age, comorbidities, baseline blood pressure, and baseline number of blood pressure medications.

      Results

      A total of 573 patients were referred to the hypertension program; 86% (465/543) had at least 1 matched control and were included as cases in the analyses; 3:1 matching was achieved in 90% (418/465) of cases. At baseline, cases and controls did not differ with respect to age, gender, race, or comorbidity; baseline blood pressure was higher (139.9/80.0 mm Hg vs 136.7/78.2 mm Hg, P ≤ .0002) in the cases compared with controls. Multivariate regression modeling identified significantly lower systolic blood pressure for the cases compared with controls at both 6 and 12 months (6-month risk ratio [RR], 9.7; 95% confidence interval [CI], 2.7-35.3; 12-month RR, 20.3; 95% CI, 4.1-99.2; P < .01 for both comparisons). Diastolic blood pressure was significantly lower at 12 months (RR, 2.9; 95% CI, 1.2-7.1; P < .01) but not at 6 months (RR, 1.0; 95% CI, 0.31-3.4; P = .9) for the cases compared with controls.

      Conclusions

      Patients who were referred to the pharmacist hypertension care management program had a significant improvement in most blood pressure outcomes. This program may be an effective method of improving blood pressure control among patients in a medical home model of primary care.

      Keywords

      SEE RELATED EDITORIAL p. 443
      Clinical Significance
      • Systolic blood pressure was lower for cases compared with controls at 6 and 12 months (6-month risk ratio [RR], 9.7; 95% confidence interval [CI], 2.7-35.3; 12-month RR, 20.3; 95% CI, 4.1-99.2; P < .01).
      • Diastolic blood pressure was lower at 12 months (RR, 2.9; 95% CI, 1.2-7.1; P < .01) but not at 6 months (RR, 1.0; 95% CI, 0.31-3.4; P = .9) for cases compared with controls.
      • Pharmacist hypertension care management may be an effective method of improving blood pressure in a medical home model of primary care.
      An interdisciplinary approach is a strategy that significantly and consistently improves blood pressure control.
      • Carter B.L.
      • Rogers M.
      • Daly J.
      • Zheng S.
      • James P.A.
      The potency of team-based care interventions for hypertension: a meta-analysis.
      • Proia K.K.
      • Thota A.B.
      • Njie G.J.
      • et al.
      Team-based care and improved blood pressure control: a community guide systematic review.
      • Santschi V.
      • Chiolero A.
      • Burnand B.
      • Colosimo A.L.
      • Paradis G.
      Impact of pharmacist care in the management of cardiovascular disease risk factors: a systematic review and meta-analysis of randomized trials.
      • Walsh J.M.
      • McDonald K.M.
      • Shojania K.G.
      • et al.
      Quality improvement strategies for hypertension management: a systematic review.
      • Walsh J.M.
      • Sundaram V.
      • McDonald K.
      • Owens D.K.
      • Goldstein M.K.
      Implementing effective hypertension quality improvement strategies: barriers and potential solutions.
      Interdisciplinary teams typically include nonphysician providers, such as pharmacists and nurses, who focus on hypertension care. One meta-analysis on the potency of team care interventions found that interventions involving clinical pharmacists resulted in lower blood pressure and greater likelihood of achieving blood pressure control.
      • Carter B.L.
      • Rogers M.
      • Daly J.
      • Zheng S.
      • James P.A.
      The potency of team-based care interventions for hypertension: a meta-analysis.
      The potency of team care programs has been attributed not only to the specific intervention(s) used but also to the duration of the program, the type of organization, and the design of the trial to measure effectiveness of the program. In another systematic review on the effect of pharmacists as team members, Chisholm-Burns et al
      • Chisholm-Burns M.A.
      • Kim Lee J.
      • Spivey C.A.
      • et al.
      US pharmacists' effect as team members on patient care: systematic review and meta-analyses.
      found that pharmacist participation significantly improved outcomes for hypertension.
      In the evolving patient-centered medical home model, the pharmacist's role as part of the interdisciplinary team has been described.
      • Smith M.
      • Bates D.W.
      • Bodenheimer T.
      • Cleary P.D.
      Why pharmacists belong in the medical home.
      Within the patient-centered medical home, referral to a clinical pharmacist for hypertension management is associated with improved patient outcomes and provides primary care clinicians with additional time to focus on other patient priorities.
      • Smith M.C.
      • Boldt A.S.
      • Walston C.M.
      • Zillich A.J.
      Effectiveness of a pharmacy care management program for veterans with dyslipidemia.
      Adoption and implementation of a patient-centered medical home (or Patient-Aligned Care Team) model are ongoing at Veterans Affairs (VA) Medical Centers. The model establishes a group of practitioners, including physicians, nurses, pharmacists, social workers, and additional specialties, to partner with patients for a holistic and efficient primary care experience. This interdisciplinary model unites the healthcare team and improves outcomes by focusing on patient-centered care, but the effect of the pharmacist within the VA patient-aligned care team model is largely unknown. The purpose of the present study was to evaluate the effectiveness of pharmacists as part of the patient-aligned care team for veterans with hypertension.

      Materials and Methods

      Study Setting

      This study was conducted at an urban Midwest VA Medical Center that provides inpatient and outpatient health care services to approximately 200,000 veterans. Within primary care, services are provided across multiple clinics. Within each clinic, Patient-Aligned Care Team teamlets provide direct patient care; each teamlet consists of the patient, the clinician (usually a physician but in some cases an advanced practice nurse), the nurse case manager (Registered Nurse), and the health technician (Licensed Practical Nurse). Clinical pharmacists, social workers, health psychologists, and support staff are designated as members of several teamlets (and are shared across teamlets within a given clinic). For this study, a care management program was evaluated for patients with hypertension provided by clinical pharmacists in 4 primary care clinics and their associated Patient-Aligned Care Team teamlets.

      Study Design

      This was a retrospective case-control study using electronic medical record data to evaluate the effectiveness of the pharmacist care management program. The study was approved by the Indiana University/Purdue University-Indianapolis Institutional Review Boards and the VA Research and Development Committee.

      Study Population

      Patients with hypertension who were referred to the care management program during a 1-year evaluation were included as possible cases. Controls included patients with hypertension, in the same primary care clinics, who were not referred to the program during the same 1-year period. All patients were followed for 12 months.

      Care Management Program

      The hypertension care management program was provided by 6 clinical pharmacists within 4 primary care clinics throughout the duration of the evaluation period. Two clinics had 1 assigned pharmacist, and the other 2 clinics had 2 pharmacists because of the larger patient volume of those clinics. All pharmacists had completed a Doctor of Pharmacy program and at least 1 year of clinical pharmacy residency training. Several pharmacists had also obtained Board Certification in Pharmacotherapy. The pharmacists operated under a scope of practice allowing them to meet individually with patients, provide patient education, and initiate, change, and discontinue medications.
      An electronic form was used by primary care providers to refer patients with hypertension to the pharmacists. During the referral process, many primary care providers would “curbside” the pharmacists to discuss initial therapy options. After referral to the program, patients were scheduled for an initial face-to-face visit with the pharmacist. Typically, the initial visit was scheduled to occur within 30 days of referral and occurred on the same day as the patient's regular primary care clinic visit. The pharmacists met with the patient for 15 to 30 minutes and measured blood pressure using standard, calibrated devices that were available to all providers in the clinic. Blood pressure measurements were conducted using the American Heart Association guidelines.
      • American Heart Association
      Heart Disease and Stroke Statistics-2004 Update.
      As part of the pharmacists' scope of practice, treatment decisions were based on national clinical practice guidelines from the Joint National Committee 7 and the VA/Department of Defense (which were the current guidelines at the time of this evaluation) using a stepwise approach to medication management.

      VA/DoD Clinical Practice Guideline for the Management of Hypertension in Primary Care. 2004. Available at: http://www.healthquality.va.gov/Hypertension_Clinical_Practice_Guideline.asp. Accessed June 25, 2010.

      • Chobanian A.V.
      • Bakris G.L.
      • Black H.R.
      • et al.
      Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
      Thiazide diuretics were preferred first-line antihypertensive medications with considerations for the use of other medications based on comorbid disease states. In general, medication dosages were maximized before additional medications were added to the regimen. Blood pressure goals were established according to guidelines; patients with diabetes and chronic kidney disease had a systolic blood pressure goal less than 130 mm Hg and a diastolic blood pressure goal less than 80 mm Hg. All other patients had a systolic blood pressure goal less than 140 mm Hg and diastolic blood pressure goal less than 90 mm Hg.
      Patients were discharged from the program once blood pressure goals were attained at a pharmacist visit or during a primary care provider visit. However, if the patients' blood pressure became uncontrolled at any subsequent primary care visits, the provider could re-refer the patient back to the pharmacist for additional management. This referral, discharge back to primary care, and re-referral process was designed to maximize the pharmacists' panel size with those patients who needed intensive treatment while maintaining the primary care providers' role in the overall care of their patients. Patients also could be discharged from the program after 2 consecutive no-show visits.

      Data Collection, Outcomes, and Analyses

      Retrospective data were extracted from the VA electronic medical record. To be included in the cohort, all unique patients with a diagnosis of hypertension (International Classification of Diseases, 9th Revision code: 401.1X-404.1X) and 1 or more primary care visits during a 1-year care management evaluation period were identified. Patients who died during the evaluation period were excluded (Figure 1). For all eligible patients, data were obtained for 1 year before the intervention, the 1-year period during the intervention evaluation, and 1 year after the intervention period. The following data elements were extracted during the 1-year period before the evaluation: gender, race, comorbid conditions based on outpatient International Classification of Diseases, 9th Revision codes (including those for diabetes and chronic kidney disease), primary care clinic assignment, primary care provider assignment, and the number of unique blood pressure medications. Additional data elements were extracted for the 1-year evaluation period and the 1-year follow-up period: dates of all primary care visits, blood pressure values (both systolic and diastolic) at each primary care visit, and blood pressure medication data (drug name, quantity, day's supply, and dates of refills).
      All patients cared for in the pharmacist hypertension care management program were considered to be potential cases. All remaining patients in the cohort were identified as potential controls and available for matching (Figure 1). Each case was matched to a maximum of 3 controls on the basis of primary care provider and clinic, age ±5 years, gender, diagnoses of diabetes and chronic kidney disease, baseline systolic blood pressure ±10 mm Hg defined as the average of the previous 3 blood pressures, and number of unique blood pressure medications at baseline. All criteria had to be met to be considered a match. All cases with 1 or more matched controls were included in the analyses.
      For cases, baseline was defined as the date of referral to care management program. For controls, patients were allocated to a baseline date that coincided with the proportion of matched cases with a baseline date during each month of the 1-year intervention period. For example, if 10% of the cases had a baseline date in June, then all 10% of those matched controls were assigned a baseline date in the month of June. All cases and matched controls were followed for 12 months from baseline.
      The primary outcomes were differences in systolic and diastolic blood pressure levels at 6- and 12-month follow-ups in the cases compared with the controls. For each time point, the average of all primary care blood pressure values during that time period was used for the outcome assessment. Secondary outcomes included the number of patients reaching national guideline-defined blood pressure goals (both systolic and diastolic blood pressure levels) at 6 and 12 months.
      Additional analyses explored the number and type of medication changes, defined as the addition of a new blood pressure medication or an increase in the dose of an existing blood pressure medication, occurring in the cases compared with the controls during the 12 months of follow-up. To explore medication adherence at 12 months, the medication possession ratio was calculated on the basis of the method described by Steiner and Prochazka
      • Steiner J.F.
      • Prochazka A.V.
      The assessment of refill compliance using pharmacy records: methods, validity, and applications.
      as a continuous, multiple-interval measure of medication availability. To account for medication switches and concurrent therapy, an average of all blood pressure drugs' medication possession ratios within a therapeutic class was computed to produce 1 averaged medication possession ratio for each class and an overall medication possession ratio for all blood pressure medications; the average medication possession ratio was then dichotomized with poor adherence defined as <0.8 and good adherence defined as ≥0.8.
      • Peterson A.M.
      • Nau D.P.
      • Cramer J.A.
      • Benner J.
      • Gwadry-Sridhar F.
      • Nichol M.
      A checklist for medication compliance and persistence studies using retrospective databases.
      Descriptive statistics were calculated to characterize the baseline demographics of both groups. Multivariate linear regression models compared each blood pressure end point at 6 and 12 months between the cases and controls adjusting for age, comorbidities, baseline blood pressure, and baseline number of blood pressure medications. Logistic regression models, using similar covariates, evaluated achievement of blood pressure goals. Given that missing data for the blood pressure outcomes measurement were not random and dependent on factors such as clinic follow-up, a not completely at random multiple imputation method was used for the blood pressure values.
      • Graham J.W.
      Missing data analysis: making it work in the real world.
      • He Y.
      Missing data analysis using multiple imputation: getting to the heart of the matter.
      Data were analyzed using SAS (SAS Institute Inc, Cary, NC) and R, with all P values less than .05 considered to be statistically significant.

      Results

      Eighty-six percent (465/543) of program participants had at least 1 matched control and were included in the analyses as cases (Figure 1). Three-to-one matching was achieved in 90% of participants (418/465), and 18 patients (4%) had a 2-1 match and 29 patients (6%) had a 1-1 match. Cases and matched controls all came from the same matched physicians and clinics and did not differ with respect to age, race, gender, or comorbidities (Table 1). Baseline blood pressure was higher (139.9/80.0 mm Hg vs 136.7/78.2 mm Hg; P ≤ .0002) and baseline blood pressure control was lower (35% vs 49%, P < .0001) in the cases compared with controls. Among cases, systolic blood pressure decreased from baseline by −4.0 and −7.1 mm Hg at 6 and 12 months, respectively, whereas among controls, systolic blood pressure decreased by −1.6 and −2.6 mm Hg at 6 and 12 months, respectively. Among cases, diastolic blood pressure decreased from baseline by −2.5 and −3.2 mm Hg at 6 and 12 months, respectively, whereas among controls, diastolic blood pressure decreased from baseline by −1.1 and −1.2 mm Hg at 6 and 12 months, respectively.
      Table 1Baseline Characteristics of Cases and Controls
      CharacteristicsCases (n = 465)Controls (n = 1268)
      Male, No. (%)465 (100)1268 (100)
      Age, mean (SD), y62.6 ± 11.963.2 ± 11.5
      White, No. (%)148 (31)451 (35)
      Black, No. (%)67 (15)175 (14)
      Other/unknown, No. (%)250 (54)642 (51)
      Diabetes, No. (%)160 (34)433 (34)
      Kidney disease, No (%)15 (3)32 (3)
      No. of comorbidities, mean (SD)
      Calculated from the Elixhauser comorbidity index.
      2.6 ± 1.22.5 ± 1.2
      Baseline systolic blood pressure, mean (SD), mm Hg
      Statistically significant difference between cases and controls using t test or chi-square test as appropriate (P < .05).
      139.9 ± 11.0136.7 ± 10.6
      Baseline diastolic blood pressure, mean (SD), mm Hg
      Statistically significant difference between cases and controls using t test or chi-square test as appropriate (P < .05).
      80.0 ± 9.378.2 ± 8.7
      Baseline blood pressure control, No. (%)
      Statistically significant difference between cases and controls using t test or chi-square test as appropriate (P < .05).
      164 (35)617 (49)
      Baseline No. of blood pressure medications, mean (SD)
      Statistically significant difference between cases and controls using t test or chi-square test as appropriate (P < .05).
      3.3 ± 1.62.9 ± 1.4
      Baseline Medication Classes
       Alpha-1 blockers, No. (%)14 (3)38 (3)
       Alpha-2 agonists, No. (%)96 (21)282 (22)
       ACE inhibitors/ARBs, No. (%)294 (63)814 (64)
       Beta-blockers, No. (%)169 (36)499 (39)
       Calcium channel blockers, No. (%)110 (24)340 (27)
       Thiazide diuretics, No. (%)184 (40)528 (42)
       Other (non-loop) diuretics, No. (%)61 (13)193 (15)
       Others, No. (%)10 (2)23 (2)
      ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; SD = standard deviation.
      Calculated from the Elixhauser comorbidity index.
      Statistically significant difference between cases and controls using t test or chi-square test as appropriate (P < .05).
      By controlling for baseline covariates, multivariate regression modeling identified significantly lower systolic blood pressure for the cases compared with controls at both 6 and 12 months (6-month risk ratio [RR], 9.7; 95% confidence interval [CI], 2.7-35.3; 12-month RR; 20.3, 95% CI, 4.1-99.2; P < .01 for both comparisons). Diastolic blood pressure was significantly lower at 12 months (RR, 2.9; 95% CI, 1.2-7.1; P < .01) but not at 6 months (RR, 1.0; 95% CI, 0.31-3.4; P = .9) for the cases compared with the controls. Blood pressure control was better among cases than controls at 12 months (64% vs 60%; odds ratio, 1.3; 95% CI, 1.1-1.6; P < .01) but not at 6 months (57% vs 57%; odds ratio, 1.1; 95% CI, 0.9-1.3; P = .28).
      The medication possession ratio for all blood pressure medications and the proportion of patients with a medication possession ratio ≥80% did not differ between cases and controls at 12 months (Table 2). There were more medications added or doses increased in the cases compared with the controls for alpha-1 blockers, alpha-2 agonists, calcium channel blockers, and non-loop diuretics (Table 2).
      Table 2Medication Changes and Medication Adherence Among Cases and Controls During Follow-up Period
      CharacteristicsCasesControlsP Value
      P values calculated using t test or chi-square test as appropriate.
      Medication Possession Ratio at 12 Mo, Mean (SD)
       All blood pressure medications0.71 (0.19)0.71 (0.20).89
       Alpha-1 blockers0.69 (0.30)0.67 (0.25).78
       Alpha-2 agonists0.70 (0.21)0.68 (0.22).66
       ACE inhibitors/ARBs0.74 (0.22)0.71 (0.21).16
       Beta-blockers0.70 (0.22)0.72 (0.20).46
       Calcium channel blockers0.73 (0.22)0.72 (0.21).56
       Thiazide diuretics0.71 (0.22)0.71 (0.21).86
       Other (non-loop) diuretics0.64 (0.23)0.72 (0.23).07
       Others0.60 (0.17)0.70 (0.21).31
      Proportion of Patients with Medication Possession Ratio ≥80% at 12 Mo, No (%)
       All blood pressure medications133 (35)243 (32).69
       Alpha-1 blockers5 (29)9 (50).31
       Alpha-2 agonists16 (30)39 (33).43
       ACE inhibitors/ARBs90 (43)127 (32).03
       Beta-blockers54 (34)88 (32).26
       Calcium channel blockers67 (41)100 (36).13
       Thiazide diuretics56 (37)85 (34).62
       Other (non-loop) diuretics14 (24)36 (38).09
       Others1 (11)2 (22)>.99
      Medication Changes Occurring During 12-Mo Follow-up, No (%)
      Medication changes refer to any addition of a new blood pressure medication or an increase in the dose of an existing blood pressure medication.
       Alpha-1 blockers184 (40)391 (31).001
       Alpha-2 agonists276 (59)643 (51).001
       ACE inhibitors/ARBs198 (43)575 (45).31
       Beta-blockers193 (42)478 (38).15
       Calcium channel blockers172 (37)379 (30).005
       Thiazide diuretics186 (40)510 (40).93
       Other (non-loop) diuretics135 (29)270 (21).001
       Others26 (6)44 (3).05
      ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker.
      P values calculated using t test or chi-square test as appropriate.
      Medication changes refer to any addition of a new blood pressure medication or an increase in the dose of an existing blood pressure medication.

      Discussion

      Findings from this and other studies support the expanded role of the pharmacists as part of the patient-centered medical home to improve the hypertension and other cardiovascular outcomes of patients.
      • Smith M.C.
      • Boldt A.S.
      • Walston C.M.
      • Zillich A.J.
      Effectiveness of a pharmacy care management program for veterans with dyslipidemia.
      • Bex S.D.
      • Boldt A.S.
      • Needham S.B.
      • et al.
      Effectiveness of a hypertension care management program provided by clinical pharmacists for veterans.
      Indeed, in this VA patient-centered medical home model, pharmacists are able to prescribe and discontinue hypertension medications without direct oversight from the primary care physician, which has been identified as a driver of better blood pressure outcomes.
      • Proia K.K.
      • Thota A.B.
      • Njie G.J.
      • et al.
      Team-based care and improved blood pressure control: a community guide systematic review.
      The results of this case-control study add to evidence from 2 recently published systematic reviews of team-based care for hypertension. In a review of 14 studies, pharmacist participation in hypertension team-based care decreased systolic blood pressure by 7.8 mm Hg (95% CI, −9.7 to −5.8) and diastolic blood pressure by 2.9 mm Hg (95% CI, −3.8 to −2.0),
      • Chisholm-Burns M.A.
      • Kim Lee J.
      • Spivey C.A.
      • et al.
      US pharmacists' effect as team members on patient care: systematic review and meta-analyses.
      whereas the other review of 13 studies found that pharmacists' participation decreased median systolic blood pressure by 5.0 mm Hg and diastolic blood pressure by 1.7 mm Hg.
      • Proia K.K.
      • Thota A.B.
      • Njie G.J.
      • et al.
      Team-based care and improved blood pressure control: a community guide systematic review.
      Results from our study found similar, clinically meaningful results, decreasing systolic blood pressure by 4.0 and 7.1 mm Hg and diastolic blood pressure by 2.5 and 3.2 mm Hg at 6 and 12 months, respectively.
      This current study provides data on potential mechanisms through which these advantageous blood pressure outcomes are achieved. Our data suggest that the pharmacists' effect on blood pressure improvement is not due to improvement in medication adherence. Overall medication adherence at 12 months, as measured by the medication possession ratio, was 0.71 in both the cases and controls (P = .89). Also, the proportion of patients with good antihypertensive medication adherence (medication possession ratio ≥0.8) was 35% for the cases and 32% for the controls (P = .69). However, the number of changes for several classes of blood pressure medications, inclusive of newly added blood pressure medications or increases in existing blood pressure medication doses, occurred significantly more often in the cases compared with the controls. For example, the use of calcium channel blockers increased from 24% at baseline to 37% during follow-up in the cases compared with an increase from 27% to 30% in the controls (P = .005 for the follow-up comparison). These data reflect, to some extent, the primary role of the pharmacist in this patient-centered medical home model for hypertension care. Pharmacists were tasked with changing the medication regimen to maximize effectiveness, balancing the efficacy and safety of the medications with the preferences of the patient. Although specific data on medication adverse effects were not collected, it is possible that the hypertension drug regimens initiated by the pharmacists were more potent while avoiding or mitigating adverse effects. Future studies of pharmacist care models should capture data on outcomes related to identification and mitigation of adverse effects.
      In addition, pharmacists in the patient-centered medical home model serve as “physician extenders,” allowing the team to provide effective and efficient care while improving the Veterans' access to primary care providers. Our team evaluated a similar patient-centered medical home model within the VA for dyslipidemia and found that time to achieve low-density lipoprotein cholesterol control was 80% faster in the pharmacist care group compared with the control group (P = .002).
      • Smith M.C.
      • Boldt A.S.
      • Walston C.M.
      • Zillich A.J.
      Effectiveness of a pharmacy care management program for veterans with dyslipidemia.
      Although time to hypertension control was not examined in the current study, the results suggest that referral of patients to a pharmacist for management of hypertension is an efficient allocation of primary care provider resources, allowing the physician additional time to focus on other, more complex, priorities for the patient. Future studies should examine the time and cost savings associated with this patient-centered medical home model.

      Study Limitations

      The study findings should be considered with several limitations. First, the intermediate end point of blood pressure was the primary outcome for this study. Major end points, such as cardiovascular-related morbidity and mortality, were not examined in this internally funded, single-site study. Likewise, other patient-reported end points, such as medication adverse events and patient satisfaction, were not collected. Nevertheless, the magnitude of decrease in systolic blood pressure is clinically meaningful, where evidence from clinical trials suggests that these blood pressure changes would result in lower morbidity and mortality.
      • Chobanian A.V.
      • Bakris G.L.
      • Black H.R.
      • et al.
      Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
      In addition, the results found significantly more changes in blood pressure medications for the cases compared with controls but no significant improvements in medication adherence. It is possible that improvements in medication adherence could have occurred, but clinical nuances could not be detected using refill claims records and the medication possession ratio. In fact, pharmacists could have increased the dose of certain blood pressure medications by verbally informing the patient to double the dose and updating the medication list in the chart but without ordering a new prescription for filling or instructing patients to stop other medications that were already dispensed. Therefore, measurement of adherence using the medication possession ratio may not be sensitive to small improvements. Finally, although our retrospective case-control study was robust relative to pre–post study designs, the matching process for controls was incomplete. A stronger design, such as a prospective case-control or randomized study, would be ideal but was not possible for this unfunded work.

      Conclusions

      Patients who were referred to the pharmacist hypertension care management program had a significant improvement in blood pressure. This program may be an effective method of improving blood pressure control among veterans in the patient-centered medical home model.

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