In an earlier post, I argued that a retail pharmacy was not a good setting for providing many of the new services – such as dispensing birth control pills and naloxone without a prescription or providing expanded services under collaborative practice agreements – that new legislation allows pharmacists to provide. An article recently published by my colleagues Dave Dixon and Evan Sisson demonstrates that in the proper setting, pharmacists can successfully provide such services. (Disclaimer: I am one of the authors of the article. I feel comfortable saying great things about the results of the study because my role was limited to evaluation. I was not one of the pharmacists who provided the services described in the article.)
Dave and Evan describe their work at the Center for High Blood Pressure (CHBP), an inner-city free clinic for uninsured patients in Richmond, VA. They report results from 172 patients who received continuous care at the clinic over a 4-year period. These patients were primarily African-American and uninsured. At the beginning of the study period, a majority were obese and nearly 40% were smokers. Their mean blood pressure at the start of the study was 156/98 and only 17% were at or lower than the goal BP of 140/90.
The Center uses a collaborative practice model in which physicians or nurse practitioners (NPs) make diagnoses while pharmacists function as physician extenders focused on medication management. Pharmacists are allowed to order lab tests and to initiate, monitor and adjust drug therapy for patients for hypertension, diabetes, and dyslipidemia. Pharmacists provide about 70% of medication management for these patients. Patients are seen at least every 4 weeks until their BP is at goal, and then every 3 months. All patients see a physician or NP at least once a year.
The authors report that “the BP control rate improved to 66% during the first year and persisted throughout the study period, with 68% of patients at goal in 2013.” They also report that the BP control rate maintained by their patients ranked in the 90th percentile of National Committee for Quality Assurance Medicaid benchmarks and was better than the mean BP rate reported by commercial insurers in 2013. These are extraordinary results – pharmacists collaborating with physicians to manage the care of a low income, inner city, uninsured population achieved results better than those seen in populations of insured patients who were probably wealthier and faced fewer barriers to care. And they did it using a formulary that consisted of drug samples, $4 dollar generics, and drugs they could obtain through patient assistance programs.
The article indicates that the program’s success was due to “access to a common medical record, optimization of distinct interprofessional roles (diagnoses established by physicians and medications managed by pharmacists), frequent follow-up with evaluation, and collaborative practice agreement with sufficient scope of practice to implement medication changes at the time of the visit.”
Following up on my earlier post, I would add that the program’s success was also due to pharmacists being able to provide services in private areas, to not be preoccupied with dispensing quotas, and to be able to devote significant amounts of time and attention to each patient receiving the service. Unless, or until, community pharmacies can provide pharmacists with this type of environment, I believe it’s going to be very difficult for community pharmacists to provide higher levels of clinical services.