Pharmacist-managed hypertension therapy conversion.

The cost of treating hypertension represents a substantial percentage of total pharmacy expenditures at medical centers and by managed care organizations in the United States. The present study evaluated improvements in blood pressure control and cost savings achieved by switching 543 hypertensive patients from nifedipine gastrointestinal therapeutic system (GITS) to amlodipine and concurrently instituting an educational program directed at prescribers, nursing and pharmacy staff, and patients and family members. Before the switch, 543 patients were being treated with nifedipine GITS: 259 with 30 mg/d, 209 with 60 mg/d, and 75 with 90 mg/d. The total annual cost of primary antihypertensive therapy for this patient population was $184,698. All patients were switched from nifedipine GITS to 5 mg of amlodipine. The pharmacist saw patients at the time of the switch and at 2, 4, and 6 to 8 weeks after the change in antihypertensive therapy. Patients who did not achieve systolic blood pressure < or = 140 mm Hg or diastolic blood pressure < or = 90 mm Hg by 6 to 8 weeks after the switch were titrated to 10 mg/d amlodipine. After the conversion, 417 patients were receiving amlodipine 5 mg/d and 126 patients were ultimately titrated to 10 mg/d. Measurements made during the first 6 to 8 weeks of treatment indicated that amlodipine therapy significantly reduced blood pressure. Overall, amlodipine produced further mean reductions in blood pressure, from 140/82 to 130/76 mm Hg (p < 0.00005). The mean reduction from the time of the switch to 6 to 8 weeks was from 138/81 to 129/74 mm Hg for the patients who received 5 mg/d amlodipine (p < 0.00001) and from 147/85 to 133/79 mm Hg for the patients ultimately titrated to 10 mg/d amlodipine (p < 0.05). The total annual cost for primary antihypertensive therapy after the conversion was $136,854. We observed that conversion from nifedipine GITS to amlodipine enhanced blood pressure control and saved $47,844 in the annual cost of primary antihypertensive medication. For the 543 patients undergoing the switch, annual cost savings was $47,844. When the cost of additional antihypertensive agents discontinued after the switch to amlodipine was added to the analysis, the net annual cost savings increased to $49,578, a 27% reduction in yearly drug costs.

Implementation of a drug therapy monitoring clinic in a primary-care setting.

The development and implementation of a drug therapy monitoring clinic in the primary-care clinics of a military hospital are described. To improve patient care and decrease costs associated with treating chronic diseases, in August 1995 the pharmacy department established a drug therapy monitoring clinic. The clinic was responsible for initiating and monitoring treatment plans for patients with chronic diseases, implementing clinical guidelines, providing educational programs, collecting and analyzing outcome data, and handling requests for medication extensions. Treatment followed existing national standards and Department of Defense guidelines modified for the institution. The clinic began with one clinical pharmacy specialist, and within a year it added another clinical pharmacist and a technician. The clinic first obtained patients via consultations from providers in primary care; this was soon extended to all departments. In addition, the pharmacist was available to see walk-in patients needing medication extensions. Later, referrals came for inpatients and patients seen in the emergency room for asthma or diabetes mellitus, as well as for inpatients receiving oral anticoagulation therapy. For fiscal year 1999, the clinic saw 104 (+/- 44.3) patients per month seeking medication extensions. It also handled 24,873 clinical interventions that year, resulting in projected annual savings of $1,085,560. Chart review indicated that compliance with national standards improved dramatically for patients with diabetes mellitus or asthma followed by pharmacists compared with physician monitoring during the same period and before the clinic began. The wait time for reviewing laboratory results and for patients receiving anticoagulation therapy was eliminated, and doses were changed immediately, if needed. A comprehensive pharmacist-managed drug therapy monitoring clinic for outpatients with chronic diseases can result in positive patient outcomes and more cost-effective care.