Gail Ardery

Physician and pharmacist collaboration to improve blood pressure control.

BACKGROUND Studies have demonstrated that blood pressure (BP) control can be improved when clinical pharmacists assist with patient management. The objective of this study was to evaluate if a physician and pharmacist collaborative model in community-based medical offices could improve BP control. METHODS This was a prospective, cluster randomized, controlled clinical trial with clinics randomized to a control group (n = 3) or to an intervention group (n = 3). The study enrolled 402 patients (mean age, 58.3 years) with uncontrolled hypertension. Clinical pharmacists made drug therapy recommendations to physicians based on national guidelines. Research nurses performed BP measurements and 24-hour BP monitoring. RESULTS The mean (SD) guideline adherence scores increased from 49.4 (19.3) at baseline to 53.4 (18.1) at 6 months (8.1% increase) in the control group and from 40.4 (22.6) at baseline to 62.8 (13.5) at 6 months (55.4% increase) in the intervention group (P = .09 for adjusted between-group comparison). The mean BP decreased 6.8/4.5 mm Hg in the control group and 20.7/9.7 mm Hg in the intervention group (P < .05 for between-group systolic BP comparison). The adjusted difference in systolic BP was -12.0 (95% confidence interval [CI], -24.0 to 0.0) mm Hg, while the adjusted difference in diastolic BP was -1.8 (95% CI, -11.9 to 8.3) mm Hg. The 24-hour BP levels showed similar effect sizes. Blood pressure was controlled in 29.9% of patients in the control group and in 63.9% of patients in the intervention group (adjusted odds ratio, 3.2; 95% CI, 2.0-5.1; P < .001). CONCLUSIONS A physician and pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates compared with a control group. Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00201019.

Evidence-based assessment of acute pain in older adults: Current nursing practices and perceived barriers

Objectives:To report data on current nurse practice behaviors related to evidence-based assessment of acute pain in older adults, perceived stage of adoption of pain assessment practices, and perceptions of barriers to optimal assessment in this population. Methods:Medical records from 709 older adult patients hospitalized with hip fractures from 12 acute care settings were abstracted for nurse assessment practices during the first 72 hours after admission. Questionnaires sent to nurses on study units regarding perceived stage of adoption and barriers to assessment in older adults. Results:Data revealed several areas in which pain assessment practices were not optimal. Pain was not routinely assessed every 4 hours, and pain location was assessed even less frequently. Pain behaviors were assessed more in patients with a diagnosis of dementia compared to those without dementia, but the frequency of pain behavior assessments was low. Pain was not routinely assessed within 60 minutes of administering an analgesic. Nurses reported not using optimal pain assessment practices even when they were aware of and persuaded that those practices were desirable. In addition, nurses reported that difficulty communicating with patients created the greatest challenge in managing pain. Conclusions:Our data suggest that pain is not being assessed and reassessed in a manner that is consistent with current practice recommendations in older adult patients with pathologic processes that highly suggest the presence of acute pain.

Measuring Adherence to Practice Guidelines for the Management of Hypertension: An Evaluation of the Literature

Adherence to practice guidelines is frequently used as a measure of quality of care. Numerous studies have evaluated physician adherence to hypertension guidelines by prescription data, physician survey data, or medical record review. However, most have methodological limitations that might underestimate physician adherence. Accurate and meaningful characterization of adherence rests on evaluation of varied components of hypertension care, use of explicit validated performance measures, incorporation of implicit and explicit review, and linkage of process measures to blood pressure outcomes.

Deterioration of Blood Pressure Control After Discontinuation of a Physician-Pharmacist Collaborative Intervention

Study Objective. To assess blood pressure control after discontinuation of a physician‐pharmacist collaborative intervention.

Explicit and Implicit Evaluation of Physician Adherence to Hypertension Guidelines

This study evaluated physician adherence to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) hypertension guidelines in 6 community‐based clinics. Explicit review of retrospective medical record data for patients with uncontrolled hypertension measured guideline adherence using 22 criteria. Mean overall guideline adherence was 53.5% and did not improve significantly over time. Random‐effects models demonstrated significant associations between guideline adherence and various demographic and medical predictors, including age, minority status, comorbid conditions, and number of medications. A subsequent implicit review evaluated the degree to which nonadherence was justifiable and identified factors that might have affected adherence. Nonadherence was rated as justifiable for only 6.6% of the failed explicit criteria. In general, adherence to the JNC 7 guidelines was modest even when barriers that might have affected adherence were taken into consideration.

Cluster-Randomized Trial of a Physician/Pharmacist Collaborative Model to Improve Blood Pressure Control

Background—The purpose of this study was to evaluate if a physician/pharmacist collaborative model would be implemented as determined by improved blood pressure (BP) control in primary care medical offices with diverse geographic and patient characteristics and whether long-term BP control could be sustained. Methods and Results—Prospective, cluster-randomized trial of 32 primary care offices stratified and randomized to control, 9-month intervention (brief), and 24-month intervention (sustained). We enrolled 625 subjects with uncontrolled hypertension; 54% from racial/ethnic minority groups and 50% with diabetes mellitus or chronic kidney disease. The primary outcome of BP control at 9 months was 43% in intervention offices (n=401) compared with 34% in the control group (n=224; adjusted odds ratio, 1.57 [95% confidence interval, 0.99–2.50]; P=0.059). The adjusted difference in mean systolic/diastolic BP between the intervention and control groups for all subjects at 9 months was −6.1/−2.9 mm Hg (P=0.002 and P=0.005, respectively), and it was −6.4/−2.9 mm Hg (P=0.009 and P=0.044, respectively) in subjects from racial or ethnic minorities. BP control and mean BP were significantly improved in subjects from racial minorities in intervention offices at 18 and 24 months (P=0.048 to P<0.001) compared with the control group. Conclusions—Although the results of the primary outcome (BP control) were negative, the key secondary end point (mean BP) was significantly improved in the intervention group. Thus, the findings for secondary end points suggest that team-based care using clinical pharmacists was implemented in diverse primary care offices and BP was reduced in subjects from racial minority groups. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00935077.

Translating Research into Practice Intervention Improves Management of Acute Pain in Older Hip Fracture Patients

OBJECTIVE To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults. STUDY DESIGN Experimental design with the hospital as the unit of randomization. STUDY SETTING Twelve acute care hospitals in the Midwest. DATA SOURCES (a) Medical records (MRs) of patients > or =65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients. DATA COLLECTION Data were abstracted from MRs and questions distributed to nurses and physicians. PRINCIPAL FINDINGS The Summative Index for Quality of Acute Pain Care (0-18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group ( p<.0001). CONCLUSION The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture.

A Cluster-Randomized Effectiveness Trial of a Physician-Pharmacist Collaborative Model to Improve Blood Pressure Control

Numerous studies have demonstrated the value of team-based care to improve blood pressure (BP) control, but there is limited information on whether these models would be adopted in diverse populations. The purpose of this study was to evaluate whether a collaborative model between physicians and pharmacists can improve BP control in multiple primary care medical offices with diverse geographic and patient characteristics and whether long-term BP control can be sustained. This study is a randomized prospective trial in 27 primary care offices first stratified by the percentage of underrepresented minorities and the level of clinical pharmacy services within the office. Each office is then randomized to either a 9- or 24-month intervention or a control group. Patients will be enrolled in this study until 2012. The results of this study should provide information on whether this model can be implemented in large numbers of diverse offices, if it is effective in diverse populations, and whether BP control can be sustained long term. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00935077.

Sustained Blood Pressure Control Following Discontinuation of a Pharmacist Intervention

Team‐based care can improve hypertension control. The purpose of the present study was to evaluate blood pressure (BP) control 18 months following the discontinuation of a physician‐pharmacist collaborative intervention. This was a retrospective analysis of patients who had previously participated in a prospective, cluster randomized, controlled clinical trial. Six community‐based family medicine offices were randomized to control or intervention groups. Research nurses measured BPs using an automated device during the prospective trial. The research nurses then abstracted data from medical records, including BPs, medications, changes in therapy, and laboratory values for 18 months following the discontinuation of the 6‐month prospective trial. The study included 228 patients in the control (n=146) or intervention (n=82) groups. The control group contained more patients with diabetes or chronic kidney disease (P<.013), were older (P=.047), and had more coexisting conditions (P<.001) than the intervention group. Systolic BP 9 months following discontinuation of the physician‐pharmacist intervention was 137.2±18.2 mm Hg and 129.8±13.3 mm Hg in the control and intervention groups, respectively (P=.0015). BP control was maintained in 61 (41.8%) control patients and 55 (67.1%) intervention patients (P=.0003). At 18 months post‐intervention, systolic BP was 138.1±20.4 mm Hg and 130.0±16.0 mm Hg in the control and intervention groups, respectively (P=.023). BP control was maintained in 53 (36.3%) control patients and 55 (67.1%) intervention patients at 18 months post‐intervention (P<.0001). A sensitivity analysis was conducted to address the uneven distribution of patients with diabetes or chronic kidney disease, and the differences between groups were still significant. BP control rates remained significantly higher following a physician‐pharmacist intervention compared with usual care for 18 months after discontinuation of the intervention. This model has the potential value as a useful long‐term strategy to benefit patients with hypertension. J Clin Hypertens (Greenwich). 2011;13:431–437. ©2011 Wiley Periodicals, Inc.

COST EFFECTIVENESS OF A PHYSICIAN-PHARMACIST COLLABORATION INTERVENTION TO IMPROVE BLOOD PRESSURE CONTROL

Previous studies have demonstrated the cost-effectiveness of physician–pharmacist collaborations to improve hypertension control. However, most studies have limited generalizability, lacking minority and low-income populations. The Collaboration Among Pharmacist and Physicians to Improve Blood Pressure Now (CAPTION) trial randomized 625 patients from 32 medical offices in 15 states. Each office had an existing clinical pharmacist on staff. Pharmacists in intervention offices communicated with patients and made recommendations to physicians about changes in therapy. Demographic information, blood pressure (BP), medications, and physician visits were recorded. In addition, pharmacists tracked time spent with each patient. Costs were assigned to medications and pharmacist and physician time. Cost-effectiveness ratios were calculated based on changes in BP measurements and hypertension control rates. Thirty-eight percent of patients were black, 14% were Hispanic, and 49% had annual income <