番茄社区

SAN DIEGO -- Across the country, nurse- and pharmacist-led hypertension clinics consistently found it feasible to get blood pressures (BPs) at or close to goal quickly -- within a matter of weeks, even -- according to single-center reports.

In posters presented here at the annual Hypertension Scientific Sessions hosted by the American Heart Association, researchers reported success with these multidisciplinary hypertension clinics across a range of geographic settings:

• Registered nurse (RN)- and pharmacist-led clinic in Bozeman, Montana: 74% of 321 patients met BP goal within 12 weeks, with systolic BP dropping from 141.8 to 133.4 mmHg

• Pharmacist-run clinic in rural Appalachia: 38 patients saw average BP fall significantly from around 160/85 to 140/80 mmHg after 6 months

• Pharmacist-led clinic in Boston: 29 people had BP go from 155.2/89.7 to 132.1/77.6 mmHg after 6 weeks, with the proportion of people meeting BP goal rising to 31.0% from 0%

"I congratulate [the] efforts to not only provide additional evidence for the effectiveness of pharmacist-led hypertension management programs, but also raise awareness [and] encourage broader implementation and hopefully a push towards more autonomy and better reimbursement of pharmacist care on a national level," commented Florian Rader, MD, of Cedars-Sinai Medical Center in Los Angeles.

These clinics follow in the footsteps of the famous Los Angeles Barbershop Blood Pressure study conducted by Rader's institution. Reported in 2018, that study produced clinically important BP drops in African-American men by bringing in a prescribing pharmacist to their local barbershop appointments. Improvements in BP were observed at the 6-month mark.

"The reason for the success of this and other hypertension management programs is quite simple: focus on a specific disease, have clear treatment goals, and reach those with more frequent patient-healthcare provider interactions. In addition, most of such programs have evidence-based protocols for medication titration," Rader told 番茄社区.

However, there are challenges that make implementing these programs less feasible in some areas.

"One main barrier is that a pharmacist's scope of practice varies from state to state. In some states there are significant limitations to what a pharmacist can or cannot do and how their service is reimbursed," Rader noted, adding that the reimbursement is currently "sub-par."

Jordan Overstreet, DNP, APRN, of Bozeman Health in Montana, who reported her group's results with a multidisciplinary clinic, acknowledged that Montana pharmacists in particular are allowed collaborative practice agreements with physicians.

"Future work seeks to expand the reach of the clinic into our community with the implementation of an outside referral protocol. This would allow patients whose primary care provider practices outside the organization to receive innovative, guideline-directed hypertension care," she said.

Rader noted that as a whole, "ample" evidence supports pharmacy-led preventative cardiovascular programs being more effective and efficient than usual, physician only-led approaches to hypertension control.

Indeed, primary care physicians take on average 6-12 months to get patients to BP goal, according to Overstreet. Her nurse- and pharmacist-led clinic was started in 2019 in Bozeman, a small but growing city. Referred by primary care, patients visited the clinic where a registered pharmacist read and signed their charts, which were subsequently routed back to the primary care provider.

Study participants were followed every 2-4 weeks with visits with the hypertension RN until their BP and personal goals were met. As not all patients reached goal by 12 weeks, the center has added a nurse practitioner to treat patients requiring higher complexity of care, Overstreet noted.

Medication management was also a large component of the Appalachian and Boston programs.

The latter tested the impact of home BP monitoring coupled with a rapid, biweekly, pharmacist-led BP medication titration program. People with hypertension self-measured BP using a validated device twice a day for 1 week, then had their medications adjusted every 2 weeks until reaching goal or completing 6 weeks of follow-up.

Such aggressive titration appeared safe; there were no falls or instances of hypotension. One person had an electrolyte change requiring medication adjustment, and two people had significant changes in serum creatinine that required medication change, according to the poster by Anthony Ishak, PharmD, of Beth Israel Deaconess Medical Center in Boston.