Long-Term Data on Pharmacist Interventions in Hypertension

New York—Long-term follow-up data found that team-based, pharmacist intervention helped patients with hypertension control their blood pressure (BP) during the year of intervention, according to a 3-arm, randomized, controlled trial. However, there were no significant differences in BP in the years after the intervention was stopped.

Beverly Green, MD, presented the results of the Electronic Communications and Home Blood Pressure Monitoring study at the ASH meeting. The National Heart, Lung and Blood Institute supported the trial. The authors analyzed BP readings from electronic health records (EHRs) 66 months after randomization, and they conducted in-person visits 54 months after randomization.

Dr. Green said there were no predictors of long-term BP control, which she said “astounded” her. Factors including age, sex, race, education, body mass index, weight changes, number of medications, changes in medications, and adherence to medications did not predict BP control.

Based on EHR data, pharmacist intervention led to significantly lower BP for up to 3 years. By 5.5 years, the groups improved their BP, but there was no significant differences in BP control.

“We do not know, had we maintained the connection with the team care longer or provided people with booster interventions when they became out of control, whether we would have seen bigger differences,” Dr. Green said.

The study was conducted at 10 primary care medical centers within Group Health Cooperative, an integrated healthcare delivery system based in Seattle, Washington. The nonprofit system, which provides medical coverage and care to >540,000 residents of Washington and Idaho, has used EHRs for more than a decade. Patients were able to sign-up for a secure email address and access a Web site to view parts of their medical information.

One-year results were published previously [JAMA. 2008;299(24):2857-2867]. Dr. Green noted that home BP monitoring led to a modest reduction in systolic BP (SBP), while pharmacist care management led to a larger improvement. Patients receiving pharmacist interventions were nearly twice as likely to result in controlled BP after 1 year, according to Dr. Green.

In this study, the authors followed-up 12 months later, during which patients had not received interventions. They found that there was still a modest improvement in hypertension control for patients who received pharmacist interventions, although the improvements were not as profound as a year earlier.

Although hypertension is the most common diagnosis made in primary care, Dr. Green said
approximately only half of patients with hypertension have controlled BP. She and the other researchers were interested in testing whether home-based care improved BP control compared with office-based care.

Patients were eligible for inclusion if they were 25 to 74 years of age, had a hypertension diagnosis, were receiving medications, and had access to their EHRs, the Internet, and email. They were excluded if they had diabetes and heart disease because the pharmacists were providing titration medications, which had not been studied often.

Before enrolling patients, research assistants made sure that the patients could use a computer, had an email address, and had regular access to the Internet. Eligible patients were brought in for 2 research visits and were required to have uncontrolled BP at both visits, which was defined as SBP >140 mm Hg or diastolic BP >90 mm Hg.

The study included 778 patients who were randomized into 3 groups: (1) 258 in the usual care group; (2) 259 in the home BP monitoring group; and (3) 261 in the Internet-based pharmacy collaborative care group. The groups were well-balanced. The mean age was 59.1 years, 52.2% were female, 82.8% were white, 31.6% were overweight, and 61.1% were obese.

Patients in the usual care group registered to use the Group Health Cooperative Web site, received pamphlets on BP control, and were told that their BP was not controlled and they should work with their physician to improve control. Patients in the home BP monitoring group had the same interventions as the usual care group, but they also received BP monitoring and training, instruction on how to use the secure Web site, and encouragement to send their BP readings via email to their physicians. Patients in the Internet-based pharmacy collaborative care group received the same care as the other 2 groups, but they also had team-based care provided by a pharmacist. The pharmacist called the patient initially and made a plan that included their BP monitoring, medications, and lifestyle goal to reduce BP. Pharmacists followed stepped medication protocols until BP was controlled.

Seventy percent of patients came in for a follow-up visit. Patients who did not come in for a follow-up visit had higher BP at the end of the study compared to patients who did come in, according to Dr. Green, which she said may have introduced some bias.—Tim Casey