Primary care-based, pharmacist-physician collaborative medication-therapy management of hypertension: a randomized, pragmatic trial.

PURPOSE: A collaborative pharmacist-primary care provider (PharmD-PCP) team approach to medication-therapy management (MTM), with pharmacists initiating and changing medications at separate office visits, holds promise for the cost-effective management of hypertension, but has not been evaluated in many systematic trials. The primary objective of this study was to examine blood pressure (BP) control in hypertensive patients managed by a newly formed PharmD-PCP MTM team versus usual care in a university-based primary care clinic. METHODS: This randomized, pragmatic clinical trial was conducted in hypertensive patients randomly selected for PharmD-PCP MTM or usual care. In the PharmD-PCP MTM group, pharmacists managed drug-therapy initiation and monitoring, medication adjustments, biometric assessments, laboratory tests, and patient education. In the usual-care group, patients continued to see their PCPs. Participants were aged ≥ 18 years, were diagnosed with hypertension, had a most recent BP measurement of ≥ 140/≥ 90 mm Hg (≥ 130/≥ 80 mm Hg if codiagnosed with diabetes mellitus), were on at least 1 antihypertensive medication, and were English speaking. The primary outcome was the difference in the mean change from baseline in systolic BP at 6 months. Secondary outcomes included the percentage achieving therapeutic BP goal and the mean changes from baseline in diastolic BP and low- and high-density lipoprotein cholesterol. FINDINGS: A total of 166 patients were enrolled (69 men; mean age, 67.7 years; PharmD-PCP MTM group, n = 75; usual-care group, n = 91). Mean reduction in SBP was significantly greater in the PharmD-PCP MTM group at 6 months (-7.1 [19.4] vs +1.6 [21.0] mm Hg; P = 0.008), but the difference was no longer statistically significant at 9 months (-5.2 [16.9] vs -1.7 [17.7] mm Hg; P = 0.22), based on an intent-to-treat analysis. In the intervention group, greater percentages of patients who continued to see the MTM pharmacist versus those who returned to their PCP were at goal at 6 months (81% vs 44%) and at 9 months (70% vs 52%). No significant between-group differences in changes in cholesterol were detected at 6 and 9 months; however, the mean baseline values were near recommended levels. The PharmD-PCP MTM group had significantly fewer PCP visits compared with the usual-care group (1.8 [1.5] vs 4.2 [1.0]; P < 0.001). IMPLICATIONS: A PharmD-PCP collaborative MTM service was more effective in lowering BP than was usual care at 6 months in all patients and at 9 months in patients who continued to see the pharmacist. Incorporating pharmacists into the primary care team may be a successful strategy for managing medication therapy, improving patient outcomes and possibly extending the capacity of primary care. ClinicalTrials.gov identifier: NCT01973556.

Medication regimen complexity in patients with uncontrolled hypertension and/or diabetes.

OBJECTIVES: To compare medication regimen complexity (MRC) for patients with uncontrolled hypertension, uncontrolled diabetes, or both, to examine the contribution of complexity components (dosage form, frequency, additional directions) to total MRC index (MRCI) score, and to explore the relationship of MRC with patient characteristics and medication regimen cost. METHODS: This cross-sectional retrospective study used electronic medical record data for patients' most recent visit to a university internal medicine clinic during 2009. MRCI scores (disease specific and patient level [medications for all conditions]) were calculated for adults with uncontrolled hypertension, diabetes, or both (i.e., not at recommended treatment goals). RESULTS: 206 patients (85 with hypertension, 60 with diabetes, and 61 with both) were included. The median (range) disease-specific MRCI was significantly greater for diabetes (8.0 [3-21]) than for hypertension (3.0 [2-11], P < 0.001), though the median number of disease-specific medications was identical (2). The majority of hypertension MRC was the result of dosage frequency (62.1%), while diabetes MRC was distributed among dosage form (38.3%), frequency (39.1%), and additional directions (27.6%). The median patient-level MRCI scores for each group were 11 to 15 points higher than the disease-specific MRCI scores. Higher MRCI scores were associated with higher regimen cost, comorbidity burden, and female gender. CONCLUSION: The magnitude of MRCI scores varied across the three disease groups, increased dramatically when all medications were considered, and revealed greater complexity than a simple count of prescribed medications. The MRCI may be a useful tool for targeting patients for whom medication therapy management services would be most beneficial and cost effective.

Falsely low hemoglobin A1c levels in a patient receiving ribavirin and peginterferon alfa-2b for hepatitis C.

The effect of treatment for hepatitis C viral infection on hemoglobin A(1c) (A1C) levels is not well described in the literature. We describe a 59-year-old man with type 2 diabetes mellitus whose A1C level became falsely low when ribavirin and peginterferon alfa-2b therapy were started for treatment of hepatitis C. After treatment was discontinued, the patient's A1C returned to its previous baseline value. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 7) between the patient's low AIC level and his ribavirin-peginterferon alfa-2b therapy. Clinicians should be aware that combination therapy for hepatitis C may affect A1C values. To maintain accurate glucose control in patients with diabetes who are receiving treatment for hepatitis C, it is important that they self-monitor their blood glucose levels in conjunction with A1C data, especially when A1C values become falsely low.