Using pharmacy consults to improve blood pressure control in a resident teaching clinic

Patients receiving care in resident teaching clinics are often vulnerable to healthcare disparities given limited socioeconomic resources and lower health literacy. In our resident clinic, a substantial proportion of patients (63%) had uncontrolled blood pressure (BP). Strategies that assign some responsibilities to a health professional other than the treating physician are associated with improved BP outcomes.1 One meta-analysis found that pharmacist interventions, including medication management, reminder systems, patient education, BP measurements and physician feedback, were superior to ‘usual care’ for BP control.2 We incorporated these concepts into a quality improvement (QI) project aimed at improving BP control in our resident teaching clinic. Between October 2015 and March 2017, resident physicians were asked to refer patients aged ≥18 years with BP >140/90 mmHg on at least one antihypertensive agent to a pharmacist-driven modified medication therapy management (MMTM) program. All patients participating in the study consented to pharmacy consultation. The MMTM program focused on medication reconciliation, medication errors, treatment barriers and strategies to address barriers. When possible, patients’ refills were synchronised so only one monthly pharmacy visit would be required. Patients were educated on diet, as well as on harms associated with uncontrolled hypertension. Each patient received a free BP kit with hands-on instruction for use, a pill box and motivational tips for compliance. Initially three MMTM sessions were planned, but these were subsequently consolidated into a single session because many patients could not attend multiple sessions. Summaries were sent to the resident physician. Our MMTM was somewhat unique given its focus on a specific disease process; although not specifically validated in the literature, this modification was made to facilitate pharmacy dispensing and time limitations while embracing the core concepts of medication therapy management. Of 35 referred patients, 65.7% (n = 23) attended one or more MMTM sessions, whereas 34.3% (n = 12) did not participate. The cumulative average decrease in BP was 21.35/11.57 mmHg relative to initial BP (p < 0.001; 95% confidence interval (CI) −31.29, −11.40), and sustained BP control was achieved in 52% (n = 12) of MMTM attendees at study end. Of referred patients who did not attend a session, 41.6% (n = 5) reached goal BP at study end. The relative difference in BP between attendees and non-attendees was 4.93/–1.59 mmHg; patients who attended one or more MMTM sessions had greater reductions in systolic BP (Figure 1). Patient-cited treatment barriers included ‘forgetting’ taking and/or refilling medications (34.7%), transportation issues (30.4%) and medication cost (21.7%). Although free to all, the number of referrals to MMTM sessions was small. This may be related to the number of steps required to trigger a consult and/or lack of awareness of the available intervention. These issues will be addressed in our next QI cycle, with institution of an electronic order entry to better fit typical workflow patterns. Despite this, we believe utilisation of pharmacist-driven MMTM programs in resident clinics can improve care in vulnerable populations, noting sustained improvement in BP (on average, 11.8 months) in our small sample of patients in a community hospital resident teaching clinic. Interestingly, referral alone, without MMTM session attendance, appeared to positively affect BP control, perhaps secondary to increased awareness of both the resident physician and patient. Further study is needed. The authors acknowledge the help and assistance of Nicholas Mizenko and Rhonda Collins. This project would not have been possible without their valuable contributions to the design and implementation of this program. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. No author has any personal interest or relationship, financial or otherwise, that would present a potential source of conflict of interest to this project.