Alan J. Zillich

Influential Characteristics of Physician/Pharmacist Collaborative Relationships

BACKGROUND A theoretical model of physician/pharmacist collaborative relationships, driven by 3 groups of relationship characteristics termed participant, context, and exchange, has been developed. There are no studies that have examined the types of characteristics which most influence development of collaborative relationships between physicians and pharmacists. OBJECTIVE To test the model and determine which drivers most influence physician/pharmacist collaboration. METHODS Data on the relationship drivers and collaborative practice were collected via a mailed survey of a random sample of 1000 primary care physicians in Iowa. Participant variables include demographics; context drivers refer to the practice environment and professional interactions between physicians and pharmacists. Exchange characteristics describe the nature of social exchange and were elicited using scores from 3 domains (relationship initiation, trustworthiness, role specification) of the Physician/Pharmacist Collaboration Instrument (PPCI). Five additional questions asked about the physicians collaborative practice with a pharmacist. Hierarchical linear regression analysis was performed with collaborative practice as the dependent variable and measures of participant, context, and exchange drivers as independent variables. RESULTS Three hundred forty usable surveys (34%) were returned. Almost 70% of the respondents were male and aged 45.8 ± 9.9 years (mean ± SD). The majority were family practice physicians (72.1%) in private practice (67.3%). Regression analyses produced an R2 = 0.804 (p < 0.001). Significant predictors in the model were internal medicine physicians, professional interaction with a pharmacist, and the 3 domains of exchange drivers from the PPCI (p < 0.05). CONCLUSIONS Although participant and context factors influenced physician/pharmacist collaborative relationships, exchange characteristics were the most influential relationship drivers. Role specification, trustworthiness, and relationship initiation were positively associated with physician/pharmacist collaborative practice. Recognition of these drivers may help pharmacists who are developing collaborative working relationships with physicians. But, studies are needed to delineate other factors that may influence physician/pharmacist relationships.

Hypertension outcomes through blood pressure monitoring and evaluation by pharmacists (HOME study)

OBJECTIVE: To evaluate the effectiveness of a community pharmacist-based home blood pressure (BP) monitoring program.DESIGN: Trial of a high-intensity (HI) versus low-intensity (LI) intervention randomized in 12 community pharmacies. The HI intervention comprised 4 face-to-face visits with a trained pharmacist. Pharmacists provided patient-specific education about hypertension. Following the first and third visits, patients were provided with a home BP monitoring device and instructed to measure their BP at least once daily for the next month. Home BP readings were used by the pharmacists to develop treatment recommendations for the patient’s physician. Recommendations were discussed with the physician and, if approved, implemented by the pharmacist. In the LI intervention, pharmacists measured patients BP in the pharmacy and referred them to their physician for evaluation.PARTICIPANTS: Patients with uncontrolled BP at baseline.MEASUREMENTS: The main outcomes were the differences in systolic and diastolic BP (SBP and DBP) from baseline to follow-up between the HI and LI patients.RESULTS: The study enrolled 125 patients, 64 in the HI and 61 in the LI group. From baseline, SBP declined 13.4 mmHg in the HI group and 9.0 mmHg in the LI group. At the final visit, the difference in SBP/DBP change between the HI and LI group was −4.5/−3.2 mmHg (P=.12 for SBP and P=.03 for DBP).CONCLUSIONS: The HI intervention achieved a lower DBP and this model could be a strategy for patients with hypertension.

Exploring successful community pharmacist-physician collaborative working relationships using mixed methods

BACKGROUNDnCollaborative working relationships (CWRs) between community pharmacists and physicians may foster the provision of medication therapy management services, disease state management, and other patient care activities; however, pharmacists have expressed difficulty in developing such relationships. Additional work is needed to understand the specific pharmacist-physician exchanges that effectively contribute to the development of CWR. Data from successful pairs of community pharmacists and physicians may provide further insights into these exchange variables and expand research on models of professional collaboration.nnnOBJECTIVEnTo describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using a published conceptual model and tool for quantifying the extent of collaboration.nnnMETHODSnA national pool of experts in community pharmacy practice identified community pharmacists engaged in CWRs with physicians. Five pairs of community pharmacists and physician colleagues participated in individual semistructured interviews, and 4 of these pairs completed the Pharmacist-Physician Collaborative Index (PPCI). Main outcome measures include quantitative (ie, scores on the PPCI) and qualitative information about professional exchanges within 3 domains found previously to influence relationship development: relationship initiation, trustworthiness, and role specification.nnnRESULTSnOn the PPCI, participants scored similarly on trustworthiness; however, physicians scored higher on relationship initiation and role specification. The qualitative interviews revealed that when initiating relationships, it was important for many pharmacists to establish open communication through face-to-face visits with physicians. Furthermore, physicians were able to recognize in these pharmacists a commitment for improved patient care. Trustworthiness was established by pharmacists making consistent contributions to care that improved patient outcomes over time. Open discussions regarding professional roles and an acknowledgment of professional norms (ie, physicians as decision makers) were essential.nnnCONCLUSIONSnThe findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. Relationships appeared to develop in a manner consistent with a published model for CWRs, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on high-quality pharmacist contributions.

Utility of a Questionnaire to Measure Physician-Pharmacist Collaborative Relationships

OBJECTIVEnTo examine the sensitivity and criterion validity of the 14-item Physician/Pharmacist Collaboration Index (PPCI).nnnDESIGNnSubstudy of an unblinded, randomized trial of pharmacist interventions with patients with uncontrolled hypertension.nnnSETTINGn6 intervention and 6 control pharmacies in eastern Iowa.nnnPARTICIPANTSn25 community pharmacists.nnnINTERVENTIONSnPharmacists completed the PPCI at baseline and at a 3-month follow-up for each patients physician.nnnMAIN OUTCOME MEASURESnRespondents perceptions about their relationships with each patients physicians as measured through scores in three domains, Trustworthiness (TW; score range, 6-42), Role Specification (RS, 5-35), Relationship Initiation (RI, 3-21), and compared using nonparametric tests.nnnRESULTSnPharmacists mean scores of their relations with 38 different physicians (54 completed PPCIs) in the intervention group were 33.8 for TW, 23.2 for RS, and 16.4 for RI at baseline. At 3 months, the scores had improved significantly to 35.5, 25.0, and 17.4, respectively. Pharmacists scores for 43 different physicians (49 completed PPCIs) in the control group did not change significantly between baseline and 3 months (TW, 30.7 at each time point; RS, 20.3 and 19.7, respectively; RI, 14.3 at each time point).nnnCONCLUSIONnImproved scores in the intervention group suggest that collaborative relations improved between the physician and pharmacist during the 3-month study, while no such improvement was found in the control group. Since the intervention was designed to promote collaboration between pharmacists and physicians, these results support the PPCI as a tool to measure pharmacist-physician collaboration and could be used by pharmacists to benchmark collaborative relationships. Additional research is needed to corroborate the results of this study.

Effectiveness of a hypertension care management program provided by clinical pharmacists for veterans.

Study Objective. To evaluate the effectiveness of a hypertension care management program provided by clinical pharmacists.

Caring for Patients with Chronic Kidney Disease: A Joint Opinion of the Ambulatory Care and the Nephrology Practice and Research Networks of the American College of Clinical Pharmacy

An increasing number of patients are developing chronic kidney disease (CKD). Appropriate care for patients with CKD must occur in the earliest stages, preferably before CKD progresses to more severe stages. Therefore, recognition and treatment of CKD and its associated complications must occur in primary care settings. Patients with CKD often have comorbid conditions such as diabetes mellitus, hypertension, and dyslipidemia, creating specific considerations when treating these diseases. Also, these patients have CKD‐related conditions, including anemia and renal osteodystrophy, that are not traditionally evaluated and monitored by the primary care practitioner. Collectively, many opportunities exist for pharmacists who practice in the primary care setting to improve the care of patients with CKD.

The Net Fiscal Impact Of A Chronic Disease Management Program : Indiana Medicaid

In 2003 the Indiana Office of Medicaid Policy and Planning implemented the Indiana Chronic Disease Management Program (ICDMP). This paper reports on the fiscal impact of the ICDMP from the states perspective, as estimated from the outcomes of a randomized trial. Medicaid members with congestive heart failure (CHF) or diabetes, or both, were randomly assigned by practice site to chronic disease management services or standard care. The effect of the ICDMP varied by disease group and risk class: while cost savings were achieved in the CHF subgroup, disease management targeted to patients with only diabetes resulted in no significant fiscal impact.

Evaluation of specialized medication packaging combined with medication therapy management: Adherence, outcomes, and costs among medicaid patients

Background:This study evaluates the effect of a program combing specialized medication packaging and telephonic medication therapy management on medication adherence, health care utilization, and costs among Medicaid patients. Research Design:A retrospective cohort design compared Medicaid participants who voluntarily enrolled in the program (n=1007) compared with those who did not (n=13,614). Main outcome measures were medication adherence at 12 months, hospital admissions and emergency department visits at 6 and 12 months, and total paid claim costs at 6 and 12 months. Multivariate regression models were used to adjust for the effect of age, sex, race, comorbidities, and 12-month preenrollment health care utilization. Results:Measures of medication adherence were significantly improved in the program cohort compared with the usual care cohort. At 6 months, adjusted all-cause hospitalization was marginally less in the program cohort compared with the usual care cohort [odds ratio=0.73, 95% confidence interval (CI), 0.54–1.0, P=0.05]. No statistically significant differences were observed between the 2 cohorts for any of the other adjusted utilization endpoints at 6 or 12 months. Adjusted total cost at 6 and 12 months were higher in the program cohort (6-month cost ratio=1.76, 95% CI,1.65–1.89; 12-month cost ratio=1.84, 95% CI,1.72–1.97), primarily because of an increase in prescription costs. Emergency department visits and hospitalization costs did not differ between groups. Conclusions:The program improved measures of medication adherence, but the effect on health care utilization and nonpharmacy costs at 6 and 12 months was not different from the usual care group. Reasons for these findings may reflect differences in the delivery of the specialized packaging and the medication therapy management program, health care behaviors in this Medicaid cohort, unadjusted confounding, or time required for the benefit of the intervention to manifest.

A randomized, controlled pragmatic trial of telephonic medication therapy management to reduce hospitalization in home health patients.

OBJECTIVEnTo evaluate the effectiveness of a telephonic medication therapy management (MTM) service on reducing hospitalizations among home health patients.nnnSETTINGnForty randomly selected, geographically diverse home health care centers in the United States.nnnDESIGNnTwo-stage, randomized, controlled trial with 60-day follow-up. All Medicare- insured home health care patients were eligible to participate. Twenty-eight consecutive patients within each care center were recruited and randomized to usual care or MTM intervention. The MTM intervention consisted of the following: (1) initial phone call by a pharmacy technician to verify active medications; (2) pharmacist-provided medication regimen review by telephone; and (3) follow-up pharmacist phone calls at day seven and as needed for 30 days. The primary outcome was 60-day all-cause hospitalization.nnnDATA COLLECTIONnData were collected from in-home nursing assessments using the OASIS-C. Multivariate logistic regression modeled the effect of the MTM intervention on the probability of hospitalization while adjusting for patients baseline risk of hospitalization, number of medications taken daily, and other OASIS-C data elements.nnnPRINCIPAL FINDINGSnA total of 895 patients (intervention n = 415, control n = 480) were block-randomized to the intervention or usual care. There was no significant difference in the 60-day probability of hospitalization between the MTM intervention and control groups (Adjusted OR: 1.26, 95 percent CI: 0.89-1.77, p = .19). For patients within the lowest baseline risk quartile (n = 232), the intervention group was three times more likely to remain out of the hospital at 60 days (Adjusted OR: 3.79, 95 percent CI: 1.35-10.57, p = .01) compared to the usual care group.nnnCONCLUSIONSnThis MTM intervention may not be effective for all home health patients; however, for those patients with the lowest-risk profile, the MTM intervention prevented patients from being hospitalized at 60 days.

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

OBJECTIVEnThe study objective was to evaluate a pharmacist hypertension care management program within the patient-centered medical home.nnnMETHODSnThis 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.nnnRESULTSnA 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.nnnCONCLUSIONSnPatients 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.