Sherilyn K.D. Houle

Does Performance-Based Remuneration for Individual Health Care Practitioners Affect Patient Care?: A Systematic Review

BACKGROUND Pay-for-performance (P4P) is increasingly touted as a means to improve health care quality. PURPOSE To evaluate the effect of P4P remuneration targeting individual health care providers. DATA SOURCES MEDLINE, EMBASE, Cochrane Library, OpenSIGLE, Canadian Evaluation Society Unpublished Literature Bank, New York Academy of Medicine Library Grey Literature Collection, and reference lists were searched up until June 2012. STUDY SELECTION Two reviewers independently identified original research papers (randomized, controlled trials; interrupted time series; uncontrolled and controlled before-after studies; and cohort comparisons). DATA EXTRACTION Two reviewers independently extracted the data. DATA SYNTHESIS The literature search identified 4 randomized, controlled trials; 5 interrupted time series; 3 controlled before-after studies; 1 nonrandomized, controlled study; 15 uncontrolled before-after studies; and 2 uncontrolled cohort studies. The variation in study quality, target conditions, and reported outcomes precluded meta-analysis. Uncontrolled studies (15 before-after studies, 2 cohort comparisons) suggested that P4P improves quality of care, but higher-quality studies with contemporaneous controls failed to confirm these findings. Two of the 4 randomized trials were negative, and the 2 statistically significant trials reported small incremental improvements in vaccination rates over usual care (absolute differences, 8.4 and 7.8 percentage points). Of the 5 interrupted time series, 2 did not detect any improvements in processes of care or clinical outcomes after P4P implementation, 1 reported initial statistically significant improvements in guideline adherence that dissipated over time, and 2 reported statistically significant improvements in blood pressure control in patients with diabetes balanced against statistically significant declines in hemoglobin A1c control. LIMITATION Few methodologically robust studies compare P4P with other payment models for individual practitioners; most are small observational studies of variable quality. CONCLUSION The effect of P4P targeting individual practitioners on quality of care and outcomes remains largely uncertain. Implementation of P4P models should be accompanied by robust evaluation plans. PRIMARY FUNDING SOURCE None.

Paying pharmacists for patient care: A systematic review of remunerated pharmacy clinical care services.

Background: Expansion of scope of practice and diminishing revenues from dispensing are requiring pharmacists to increasingly adopt clinical care services into their practices. Pharmacists must be able to receive payment in order for provision of clinical care to be sustainable. The objective of this study is to update a previous systematic review by identifying remunerated pharmacist clinical care programs worldwide and reporting on uptake and patient care outcomes observed as a result. Methods: Literature searches were performed in several databases, including MEDLINE, Embase and International Pharmaceutical Abstracts, for papers referencing remuneration, pharmacy and cognitive services. Searches of the grey literature and Internet were also conducted. Papers and programs were identified up to December 2012 and were included if they were not reported in our previous review. One author performed data abstraction, which was independently reviewed by a second author. All results are presented descriptively. Results: Sixty new remunerated programs were identified across Canada, the United States, Europe, Australia and New Zealand, ranging in complexity from emergency contraception counseling to minor ailments schemes and comprehensive medication management. In North America, the average fee provided for a medication review is

Randomized Trial of the Effect of Pharmacist Prescribing on Improving Blood Pressure in the Community The Alberta Clinical Trial in Optimizing Hypertension (RxACTION)

68.86 (all figures are given in Canadian dollars), with

Effect of a Pharmacist-Managed Hypertension Program on Health System Costs: An Evaluation of the Study of Cardiovascular Risk Intervention by Pharmacists—Hypertension (SCRIP-HTN)

23.37 offered for a follow-up visit and

Improving hypertension management through pharmacist prescribing; the rural alberta clinical trial in optimizing hypertension (Rural RxACTION): trial design and methods

15.16 for prescription adaptations. Time-dependent fees were reimbursed at

Multidisciplinary approaches to the management of high blood pressure.

93.60 per hour on average. Few programs evaluated uptake and outcomes of these services but, when available, indicated slow uptake but improved chronic disease markers and cost savings. Discussion: Remuneration for pharmacists’ clinical care services is highly variable, with few programs reporting program outcomes. Programs and pharmacists are encouraged to examine the time required to perform these activities and the outcomes achieved to ensure that fees are adequate to sustain these patient care activities.

Case Finding: The Missing Link in Chronic Disease Management

Background— Hypertension control rates remain suboptimal. Pharmacists’ scope of practice is evolving, and their position in the community may be ideal for improving hypertension care. We aimed to study the impact of pharmacist prescribing on blood pressure (BP) control in community-dwelling patients. Methods and Results— We designed a patient-level, randomized, controlled trial, enrolling adults with above-target BP (as defined by Canadian guidelines) through community pharmacies, hospitals, or primary care teams in 23 communities in Alberta. Intervention group patients received an assessment of BP and cardiovascular risk, education on hypertension, prescribing of antihypertensive medications, laboratory monitoring, and monthly follow-up visits for 6 months (all by their pharmacist). Control group patients received a wallet card for BP recording, written hypertension information, and usual care from their pharmacist and physician. Primary outcome was the change in systolic BP at 6 months. A total of 248 patients (mean age, 64 years; 49% male) were enrolled. Baseline mean±SD systolic/diastolic BP was 150±14/84±11 mm Hg. The intervention group had a mean±SE reduction in systolic BP at 6 months of 18.3±1.2 compared with 11.8±1.9 mm Hg in the control group, an adjusted difference of 6.6±1.9 mm Hg (P=0.0006). The adjusted odds of patients achieving BP targets was 2.32 (95% confidence interval, 1.17–4.15 in favor of the intervention). Conclusions— Pharmacist prescribing for patients with hypertension resulted in a clinically important and statistically significant reduction in BP. Policy makers should consider an expanded role for pharmacists, including prescribing, to address the burden of hypertension. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00878566.

Publicly funded remuneration for the administration of injections by pharmacists: An international review.

To quantify the potential cost savings of a community pharmacy–based hypertension management program based on the results of the Study of Cardiovascular Risk Intervention by Pharmacists—Hypertension (SCRIP‐HTN) study in terms of avoided cardiovascular events—myocardial infarction, stroke, and heart failure hospitalization, and to compare these cost savings with the cost of the pharmacist intervention program.

The 2015 Canadian Hypertension Education Program (CHEP) guidelines for pharmacists An update

BackgroundPatients with hypertension continue to have less than optimal blood pressure control, with nearly one in five Canadian adults having hypertension. Pharmacist prescribing is gaining favor as a potential clinically efficacious and cost-effective means to improve both access and quality of care. With Alberta being the first province in Canada to have independent prescribing by pharmacists, it offers a unique opportunity to evaluate outcomes in patients who are prescribed antihypertensive therapy by pharmacists.MethodsThe study is a randomized controlled trial of enhanced pharmacist care, with the unit of randomization being the patient. Participants will be randomized to enhanced pharmacist care (patient identification, assessment, education, close follow-up, and prescribing/titration of antihypertensive medications) or usual care. Participants are patients in rural Alberta with undiagnosed/uncontrolled blood pressure, as defined by the Canadian Hypertension Education Program. The primary outcome is the change in systolic blood pressure between baseline and 24 weeks in the enhanced-care versus usual-care arms. There are also three substudies running in conjunction with the project examining different remuneration models, investigating patient knowledge, and assessing health-resource utilization amongst patients in each group.DiscussionTo date, one-third of the required sample size has been recruited. There are 15 communities and 17 pharmacists actively screening, recruiting, and following patients. This study will provide high-level evidence regarding pharmacist prescribing.Trial RegistrationClinicaltrials.gov NCT00878566.

Blood pressure kiosks for medication therapy management programs: Business opportunity for pharmacists

Purpose of review Studies on collaborative and multidisciplinary approaches to the management of hypertension published in the past 2 years are summarized. Expanding scopes of practice for nonphysician health professionals, a need to build capacity in the healthcare system, and a movement toward multidisciplinary care warrant an examination of the evidence in this area. Recent findings Multidisciplinary care for hypertension management, across the majority of studies identified, resulted in improved blood pressure (BP) outcomes and the timeliness of achieving treatment targets. Interventions involving therapeutic decision-making by nonphysician health professionals consistently resulted in significant BP improvements compared with usual care, whereas more passive approaches, such as education and lifestyle monitoring programs, were unable to significantly benefit participants’ BP. Summary Our findings support recent efforts to integrate collaborative care approaches into chronic disease management, with the strongest evidence for pharmacist care. Expanding scopes of practice and clinical decision-making protocols for nurses, pharmacists, dietitians, and physiotherapists have the potential to further improve hypertension care.