By Davidta Brown, Senior Staff Editor
The idea of granting pharmacists the right to prescribe, as well as to counsel and dispense, has long been a source of controversy among healthcare professionals. A study out of the University of Alberta in Canada, published online in mid-April, provided some much needed concrete data for an argument that is often difficult to quantify: how does permitting pharmacists to act as prescribers affect patient outcomes? As the first Canadian province to allow pharmacists the right to prescribe (though this power is limited to certain patient profiles), Alberta proved to be an ideal location for the study.1,2 This unique investigation managed to isolate and evaluate the effects of expanding the scope of pharmacy practice, and set the stage for future scientific inquiries into the pharmacist’s role in patient care.
The patients involved in the study had all suffered and recovered from either a minor stroke or a transient ischemic attack. According to the study’s lead author, Finlay McAlistar, this patient population is in particular need of monitoring because among stroke patients in general, “six or 12 months after their stroke, a lot of patients still had uncontrolled blood pressure and uncontrolled cholesterol,” increasing their risk of another stroke or cardiac event.3 At the start of the study, the majority of the patients were already receiving a prescription to manage their cardiovascular risk, with 78.1% of participants receiving antihypertensive drugs and 84.6% receiving statins.4 However, none of the patients met the Canadian Heart and Stroke Foundation’s targets for secondary prevention in patients at risk of stroke, which is an LDL cholesterol level of less than 2.0 mmol/L and a systolic blood pressure consistently lower than 140 mmHg.4,5,6 In the majority of patients, the deviation from the target was due to high LDL cholesterol, since many of the patients began the study with ideal systolic blood pressure.4
Each of the 279 participants were allocated to either a nurse-led case management group or a pharmacist-led group to which each patient would go for a visit once a month for six months.2,4 The nurse-led care consisted of checking each patient’s systolic blood pressure and LDL levels, providing advice about lifestyle modifications to reduce cardiovascular risk, and reporting to the patient’s primary care physician.2,4 The nurses would also suggest that patients make follow-up appointments with their physicians as needed, but would not make the appointment on the patients’ behalf.3 Patients allocated to the pharmacist-led group received the same monitoring procedures, with the addition of new or modified prescriptions at the pharmacist’s discretion. The pharmacist could initiate therapy, titrate doses, and add drugs according to a pre-established treatment algorithm if the patient’s blood pressure or LDL levels remained uncontrolled.2,3 It must also be noted that all changes or additions to a patient’s medical therapy were carried out with the knowledge of the primary care physician, with whom the pharmacist would maintain contact.2
After six months of care, 43.4% of patients in the pharmacist-led group met the recommended targets for both blood pressure and LDL cholesterol, compared with 30.9% of patient in the nurse-led group, a statistically significant difference of 12.5%.2,4 The quantitative benefit of pharmacist-led care was largely led by improvements in the proportion of patients who met the LDL targets, since “nearly two-thirds of participants were already at systolic BP targets at baseline, and patients in both groups had similar reductions in systolic blood pressure during the trial.”4 Among the reasons posed by study authors for the more significant results with LDL levels is a possible “ceiling effect” in blood pressure management, which is the idea that patients with controlled hypertension generally stabilize at a particular blood pressure level without much further decrease. Also suggested was a greater motivation among stroke survivors to monitor and control blood pressure than to control LDL, because of their greater understanding of the importance of the former.4
The study did have its share of limitations, such as the small number of study participants, a problem made more significant as 27 patients withdrew from the study early, and the impossibility of the investigation being blinded.2,4 Additionally, the six month span of the study was not enough time to conclude that pharmacist-led risk management actually translated to a reduction in future strokes or CV events, though the outcomes observed here were good predictors of such events.2
While the setting of this investigation was within the Canadian healthcare system, its researchers and authors contend that the results could be translated with relative ease to the United Kingdom’s National Health Service or to integrated managed care organizations in the United States.4 By allowing pharmacists to write and modify prescriptions with the goal of maintenance rather than cure, the patient care system tested by the University of Alberta seems to reduce the burden of these follow-up visits on primary care physicians. However, it may also represent a redefinition of practice boundaries that may be difficult for patients to adjust to.
In the United States, the idea of increased collaboration between pharmacists and physicians on patient therapy has been under discussion for several years. Pharmacists in many states have sought, and often won, legislative expansion of their professional roles, and New York State pharmacists are now taking up the cause. On September 14th 2011, a new law allowing the implementation of collaborative drug therapy management (CDTM) in a few teaching hospitals in New York State, went into effect.7 As defined in the accompanying revision to state regulation on Pharmacy education, CDTM is the “performance of services by a pharmacist relating to the review, evaluation and management of drug therapy to a patient…in accordance with a written agreement or protocol”.8 This legislation created an environment for the evaluation of increased pharmacist input in drug therapy, much like the study at the University of Alberta.
After applying principles of CDTM to anticoagulation therapy, as well as to disease states including dia
betes, heart failure, and HIV, the participating teaching hospitals transferred data on patient health and satisfaction outcomes to the New York State Education Department.9 This data was then compiled into a powerfully convincing report on the overall benefits of such collaboration bet-pharmacists and physicians, for presentation to the New York State legislature.9 (The report can be read at http:/www.op.nysed.govnews/cdtmreportmay2014final.pdf.)
The law that currently permits the practice of CDTM at selected teaching hospitals is set to expire on September 14th of 2014.8 It is hoped that the positive results indicated in the Education Department’s report will spur the creation of new laws, making CDTM a permanent and more expansive part of New York State healthcare. Such legislature would allow New York to follow in the footsteps of the 46 other states, and of our neighbor to the north, that are exploring expanded possibilities for pharmacists in enhancing patient care.9
- Pharmacists prescribing for stroke patients shows benefits, researchers say. CBC News. Available at: http://www.cbc.ca/news/health/pharmacists-prescribing-for-stroke-patients-shows-benefits-researchers-say-1.2609529. Published April 14, 2014. Accessed May 1, 2014.
- O’Riordan M. Pharmacists Managing Treatment Improves BP and Lipids in Stroke Patients. Medscape. Available at: http://www.medscape.com/viewarticle/823557. Published April 14, 2014. Accessed May 1, 2014.
- Hewko A. Pharmacists can help patients improve health after stroke: study. University of Alberta. Available at: http://news.ualberta.ca/newsarticles/2014/april/pharmacists-can-help-patients-improve-health-after-stroke. Published April 16, 2014. Accessed May1, 2014.
- McAlistar F, Majumdar S, Padwal R, et al. Casemanagement for blood pressure and lipid level control after minor stroke: PREVENTION randomized controlled trial. [Published online ahead of print April 14 2014]. CMAJ. 2014. doi: 10.1503/cmaj.140053.
- Foundation. Lipid Management. Canadian Best Practice Recommendations for Stroke Care. Available at: http://www.strokebestpractices.ca/index/php/prevention-of-stroke/lipidmanagement/. Accessed May 2, 2014.
- Heart and Stroke Foundation. Blood Pressure Management. Canadian Best Practice Recommendations for Stroke Care. Available at: http://www.strokebestpractices.ca/index/php/prevention-of-stroke/blood-pressure-management/. Accessed May 2, 2014.
- Implementation of Collaborative Drug Therapy Management (CDTM) in New York State Pursuant to Chapter 21 of the Laws of 2011. New York State Office of the Professions. Available at: http://www.op.nysed.gov/prof/pharm/cdtm-qa_02192013.pdf. Accessed June 24, 2014.
- Education Law: Article 137, Pharmacy. New York State Office of the Professions. Available at: http://www.op.nysed.gov/prof/pharm/article137.htm#sect6801-a. Accessed June 24, 2014.
- Report to the New York State Legislature: The Impact of Pharmacist-Physician Collaboration on Medication-related Outcomes. New York State Office of the Professions. Available at: http://www.op.nysed.gov/news/cdtmreportmay2014final.pdf. Published May 6, 2014. Accessed June 26, 2014.
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