Team care: Pharmacists can improve patient outcomes

Key Points

Barry Carter, PharmD, professor at the University of Iowa's College of Pharmacy, and colleagues set out to determine the effectiveness of a physician-and-pharmacist team intervention to improve blood-pressure control in patients with hypertension.

In a cluster-randomized controlled clinical trial in six community-based family medicine offices, clinical pharmacists made recommendations on blood-pressure drug therapy to physicians, basing them on national guidelines and their clinical expertise. The family medicine offices employed clinical pharmacists who had been at their locations for eight years or more.

The results were positive. In the intervention group working with the physician-pharmacist teams, blood pressure was controlled among significantly more patients (63.9 percent had blood-pressure control) than among patients in the control group, of whom only 29.9 percent had blood-pressure control. In addition, the patients' mean blood pressure was reduced by 20.7/9.7 millimeters of mercury (mm Hg) in the intervention group and by 6.8/4.5 mm Hg in the control group.

Other studies involving collaborative care for cardiovascular disease show similar positive results. Jun Ma, MD, PhD, with the Palo Alto Medical Foundation Research Institute, and colleagues conducted a randomized clinical trial, also published in the November 2009 issue of the Archives of Internal Medicine.

In a county healthcare system trial designed to reduce cardiovascular risk in low-income, ethnically diverse populations, intervention-group patients received one-to-one case-management services from trained nurse and dietitian case managers, in addition to physician care. The global cardiovascular risk scores of intervention patients declined significantly compared to those of control patients.

"This reduction is important, given the high-risk patients enrolled in the study and the disproportionate rates of cardiovascular risk historically observed in medically underserved patients," wrote Helene Levens Lipton, PhD, with the University of California - San Francisco's Department of Clinical Pharmacy, in an accompanying editorial in the Archives of Internal Medicine.

At the same time, the intervention was very resource-intensive: Each patient averaged 11.2 hours of face-to-face contact time with case managers, according to Levens Lipton.

In addition, the problem with Carter's study and others is quantifying the financial costs and benefits associated with team care. "While quality improvements made by allied health professionals are well documented, financial benefits must also accrue before widespread adoption can occur," Levens Lipton wrote.

The cost of collaborative programs is one of their primary challenges, Carter acknowledged. Insurance companies and Medicare are not currently reimbursing for collaborative pharmacist and physician services, he said, noting that "the CPT [Current Procedural Technology] codes have technically been established, but have not been valued or costed out."

While more research must be done, the medical home model, a comprehensive healthcare delivery system that emphasizes the role of primary care, can produce costs savings, according to Levens Lipton. For example, she noted, preliminary data from Geisinger Health System, an integrated delivery system, showed a 20 percent reduction in hospital admissions and a 7 percent savings in total medical costs.

Meanwhile, Carter and colleagues recently kicked off a more comprehensive blood-pressure team-care study in 27 clinics. Funded by the National Institutes of Health Heart, Lung, and Blood Institute, the physician and pharmacist teams will expand on the original blood-pressure study. "We will be looking at, if you try to sustain [blood-pressure control], whether patients will keep it up. There will be a nine-month group, a 24-month group, and a third arm is the control group," Carter said.