Evaluation of Pharmacists' Work in a Physician-Pharmacist Collaborative Model for the Management of Hypertension. A Randomized Controlled Trial of Team-Based Care: Impact of Physician-Pharmacist Collaboration on Uncontrolled Hypertension Primary care-based, pharmacist-physician collaborative medication-therapy management of hypertension: a randomized, pragmatic trial. A randomized trial of the effect of community pharmacist and nurse care on improving blood pressure management in patients with diabetes mellitus: study of cardiovascular risk intervention by pharmacists-hypertension (SCRIP-HTN). Electronic communications and home blood pressure monitoring (e-BP) study: design, delivery, and evaluation framework. Conducting a randomized controlled trial of CQI and academic detailing to implement clinical guidelines. Comparing standard care with a physician and pharmacist team approach for uncontrolled hypertension The Team Education and Adherence Monitoring (TEAM) trial: pharmacy interventions to improve hypertension control in blacks. Effect of Adding Pharmacists to Primary Care Teams on Blood Pressure Control in Patients With Type 2 Diabetes Design of a trial to evaluate the impact of clinical pharmacists and community health promoters working with African-Americans and Latinos with Diabetes Enhancing diabetes care by adding a pharmacist to the primary care team. Changing model of nursing care from individual patient allocation to team nursing in the acute inpatient environment The Role of Clinical Uncertainty in Treatment Decisions for Diabetic Patients with Uncontrolled Blood Pressure Pharmacist-physician collaboration improves blood pressure control. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. Physician-pharmacist comanagement of hypertension: a randomized, comparative trial. The Teamwork Study: enhancing the role of non-GP staff in chronic disease management in general practice. Designing and implementing a primary care intervention trial to improve the quality and outcome of care for major depression. Improving Chronic Disease Care by Adding Laypersons to the Primary Care Team Effects of Guided Care on providers' satisfaction with care: a three-year matched-pair cluster-randomized trial. Comparison of quality-of-hypertension-care indicators for groups treated by physician versus groups treated by physician-nurse team. Randomized Trial of the Effect of Pharmacist Prescribing on Improving Blood Pressure in the Community: The Alberta Clinical Trial in Optimizing Hypertension (RxACTION) Community Outreach and Cardiovascular Health (COACH) Trial: A Randomized, Controlled Trial of Nurse Practitioner/Community Health Worker Cardiovascular Disease Risk Reduction in Urban Community Health Centers
STUDY OBJECTIVE Physician-pharmacist collaborative models have been shown to improve the care of patients with numerous chronic medical conditions . Team-based health care using integrated clinical pharmacists provides one opportunity to improve quality in health care systems that use population -based financing . In November 2015 , the Centers for Medicare and Medicaid Services ( CMS ) requested that the relative value of pharmacists ' work in team-based care needs to be established . Thus the objective of this study was to describe the components of pharmacists ' work in the management of hypertension with a physician-pharmacist collaborative model . DESIGN Descriptive analysis of the components of pharmacists ' work in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now ( CAPTION ) study , a prospect i ve , cluster r and omized trial . MEASUREMENTS AND MAIN RESULTS This analysis was intended to provide policymakers with data and information , using the CAPTION study model , on the time and intensity of pharmacists ' work to underst and pharmacists ' relative value contributions in the context of CMS financing and population management aims . The CAPTION trial was conducted in 32 community-based medical offices in 15 U.S. states and included 390 patients with multiple cardiovascular risk factors .  Blood pressure was measured by trained study coordinators in each office , and patients were included in the study if they had uncontrolled blood pressure . Included patients were r and omized to a 9-month intervention , a 24-month intervention , or usual care .  The goal of the pharmacist intervention was to improve blood pressure control and resolve drug therapy problems impeding progress toward blood pressure goals . This intervention included medical record review , a structured assessment with the patient , collaboration to achieve goals of therapy , and patient follow-up . The two intervention arms ( 9 and 24 mo ) were identical the first 9 months , and that time frame is the focus of this workload evaluation . Pharmacists completed study encounter forms for every patient encounter and estimated time spent in pre-visit , face-to-face care , and post-visit activities . Among the 390 patients , there were 2811 encounters with pharmacists that involved 3.44 hours/patient for face-to-face care visits plus 1.55 hours/patient for pre-visit and post-visit work . Intensity of work was reflected in interventions to resolve drug therapy problems with patients ( 43 % of encounters ) and with physicians ( 1169 recommendations , of which physicians accepted 1153 [ 98.6 % ] ) , result ing in improvement of patients ' blood pressure goals achieved ( from 0 % at baseline to 43 % at 9 months based on the primary study end point ) . CONCLUSION Pharmacists provided extensive interventions to patients with hypertension . This analysis provides a framework for health systems , provider groups , and payers to measure pharmacists ' work in value-based financing and population management ABSTRACT OBJECTIVE Evaluate the effectiveness of collaborative management of hypertension by primary care-pharmacist teams in community-based clinics . STUDY DESIGN A 12-month prospect i ve , single-blind , r and omized , controlled trial in the Providence Primary Care Research Network of patients with hypertension and uncontrolled blood pressure . METHODS As compared to usual primary care , intervention consisted of pharmacy practitioners participating in the active management of hypertension  in the primary care office according to established collaborative treatment protocol s. At baseline , there was no significant difference in blood pressure between groups . Primary outcome measures were the differences in mean systolic and diastolic blood pressures between arms at study end . Secondary measures included blood pressure goal attainment ( < 140/90 mmHg ) , hypertension-related knowledge , medication adherence , home blood pressure monitoring , re source utilization , quality of life , and satisfaction . RESULTS A total of 463 subjects were enrolled ( n = 233 control , n = 230 intervention ) . Subjects receiving the intervention achieved significantly lower systolic ( p = 0.007 ) and diastolic ( p = 0.002 ) blood pressures compared to control ( 137/75 mmHg vs. 143/78 mmHg ) . In addition , 62 % of intervention subjects achieved target blood pressure compared to 44 % of control subjects ( p = 0.003 ) . The intervention group received more total office visits ( 7.2 vs. 4.9 , p < 0.0001 ) , however had fewer physician visits ( 3.2 vs. 4.7 , p < 0.0001 ) compared to control . Intervention subjects were prescribed more antihypertensive medications ( 2.7 vs. 2.4 , p = 0.02 ) , but did not take more antihypertensive pills per day ( 2.4 vs. 2.5 , p = 0.87 ) . There were minimal differences between groups in hypertension-related knowledge , medication adherence , quality of life , or satisfaction . CONCLUSIONS Patients r and omized to collaborative primary care-pharmacist hypertension management achieved significantly better blood pressure control compared to usual care with no difference in quality of life or satisfaction PURPOSE A collaborative pharmacist- primary care provider ( PharmD-PCP ) team approach to medication-therapy management ( MTM ) , with pharmacists initiating and changing medications at separate office visits , holds promise for the cost-effective management of hypertension , but has not been evaluated in many systematic trials . The primary objective of this study was to examine blood pressure ( BP ) control in hypertensive patients managed by a newly formed PharmD-PCP MTM team versus usual care in a university-based primary care clinic . METHODS This r and omized , pragmatic clinical trial was conducted in hypertensive patients r and omly selected for PharmD-PCP MTM or usual care .  In the PharmD-PCP MTM group , pharmacists managed drug-therapy initiation and monitoring , medication adjustments , biometric assessment s , laboratory tests , and patient education . In the usual-care group , patients continued to see their PCPs . Participants were aged ≥ 18 years , were diagnosed with hypertension , had a most recent BP measurement of ≥ 140/≥ 90 mm Hg ( ≥ 130/≥ 80 mm Hg if codiagnosed with diabetes mellitus ) , were on at least 1 antihypertensive medication , and were English speaking . The primary outcome was the difference in the mean change from baseline in systolic BP at 6 months . Secondary outcomes included the percentage achieving therapeutic BP goal and the mean changes from baseline in diastolic BP and low- and high-density lipoprotein cholesterol . FINDINGS A total of 166 patients were enrolled ( 69 men ; mean age , 67.7 years ; PharmD-PCP MTM group , n = 75 ; usual-care group , n = 91 ) . Mean reduction in SBP was significantly greater in the PharmD-PCP MTM group at 6 months ( -7.1 [ 19.4 ] vs + 1.6 [ 21.0 ] mm Hg ; P = 0.008 ) , but the difference was no longer statistically significant at 9 months ( -5.2 [ 16.9 ] vs -1.7 [ 17.7 ] mm Hg ; P = 0.22 ) , based on an intent-to-treat analysis . In the intervention group , greater percentages of patients who continued to see the MTM pharmacist versus those who returned to their PCP were at goal at 6 months ( 81 % vs 44 % ) and at 9 months ( 70 % vs 52 % ) . No significant between-group differences in changes in cholesterol were detected at 6 and 9 months ; however , the mean baseline values were near recommended levels . The PharmD-PCP MTM group had significantly fewer PCP visits compared with the usual-care group ( 1.8 [ 1.5 ] vs 4.2 [ 1.0 ] ; P < 0.001 ) . IMPLICATION S A PharmD-PCP collaborative MTM service was more effective in lowering BP than was usual care at 6 months in all patients and at 9 months in patients who continued to see the pharmacist . Incorporating pharmacists into the primary care team may be a successful strategy for managing medication therapy , improving patient outcomes and possibly extending the capacity of primary care . Clinical Trials.gov identifier : NCT01973556 BACKGROUND Blood pressure ( BP ) control in patients with diabetes mellitus is difficult to achieve and current patterns are suboptimal . Given increasing problems with access to primary care physicians , community pharmacists and nurses are well positioned to identify and observe these patients . This study aim ed to determine the efficacy of a community-based multidisciplinary intervention on BP control in patients with diabetes mellitus . METHODS We performed a r and omized controlled trial in 14 community pharmacies in Edmonton , Alberta , Canada , of patients with diabetes who had BPs higher than 130/80 mm Hg on 2 consecutive visits 2 weeks apart . Care from a pharmacist and nurse team included a wallet card with recorded BP measures , cardiovascular risk reduction education and counseling , a hypertension education pamphlet , referral to the patient 's primary care physician for further assessment or management , a 1-page local opinion leader-endorsed evidence summary sent to the physician reinforcing the guideline recommendations for the treatment of hypertension and diabetes , and 4 follow-up visits throughout 6 months .  Control-arm patients received a BP wallet card , a pamphlet on diabetes , general diabetes advice , and usual care by their physician . The primary outcome measure was the difference in change in systolic BP between the 2 groups at 6 months . RESULTS A total of 227 eligible patients were r and omized to intervention and control arms between May 5 , 2005 , and September 1 , 2006 . The mean ( SD ) patient age was 64.9 ( 12.1 ) years , 59.9 % were male , and the mean ( SD ) baseline systolic/diastolic BP was 141.2 (13.9)/77.3 ( 8.9 ) mm Hg at baseline . The intervention group had an adjusted mean ( SE ) greater reduction in systolic BP at 6 months of 5.6 ( 2.1 ) mm Hg compared with controls ( P = .008 ) . In the subgroup of patients with a systolic BP greater than 160 mm Hg at baseline , BP was reduced by an adjusted mean ( SE ) of 24.1 ( 1.9 ) mm Hg more in intervention patients than in controls ( P < .001 ) . CONCLUSION Even in patients who have diabetes and hypertension that are relatively well controlled , a pharmacist and nurse team-based intervention result ed in a clinical ly important improvement in BP . Trial Registration clinical trials.gov Identifier : NCT00374270 BACKGROUND R and omized controlled trials have provided unequivocal evidence that treatment of hypertension decreases mortality and major disability from cardiovascular disease ; however , blood pressure remains inadequately treated in most affected individuals . This large gap continues despite the facts that more than 90 % of adults with hypertension have health insurance , and hypertension is the leading cause of visits to the doctor . New approaches are needed to improve hypertension care . OBJECTIVES The Electronic Communications and Home Blood Pressure Monitoring ( e-BP ) study is a three-arm r and omized controlled trial design ed to determine whether care based on the Chronic Care Model and delivered over the Internet improves hypertension care . The primary study outcomes are systolic , diastolic , and blood pressure control ; secondary outcomes are medication adherence , patient self-efficacy , satisfaction and quality of life , and healthcare utilization and costs . METHODS Hypertensive patients receiving care at Group Health medical centers are eligible if they have uncontrolled blood pressure on two screening visits and access to the Web and an e-mail address . Study participants are r and omly assigned to three intervention groups : ( a ) usual care ; ( b ) home blood pressure monitoring receipt and proficiency training on its use and the Group Health secure patient website ( with secure e-mail access to their healthcare provider , access to a shared medical record , prescription refill and other services ) ; or ( c ) this plus pharmacist care management ( collaborative care management between the patient , the pharmacist , and the patient 's physician via a secure patient website and the electronic medical record ) . CONCLUSION We will determine whether a new model of patient-centered care that leverages Web communications , self-monitoring , and collaborative care management improves hypertension control . If this model proves successful and cost-effective , similar interventions could be used to improve the care of large numbers of patients with uncontrolled hypertension BACKGROUND A multisite , r and omized controlled trial was conducted from August 1994 through January 1996 to compare the impact of two strategies-academic detailing ( AD ) and continuous quality improvement ( CQI ) teams-on the implementation of national guidelines for the primary care of hypertension and depression . STUDY Twelve small groups of providers at four clinics-two at Group Health Cooperative of Puget Sound ( Seattle ) and two at academic medical centers-were r and omized in blocks along with their primary care patients to receive AD alone , AD plus CQI , or usual care .  A detailing session conducted by a physician and two follow-up sessions conducted by a pharmacist lasted an average of 8 - 9 minutes . Each CQI team , which met , on average , 14 times in nine months , devised at least one intervention ( for example , weight loss counseling for hypertensives by nurse practitioners ) . RESULTS The detailing endeavors differed greatly across organizations . Although all teams generally worked well together , organizational factors such as staff layoffs and reorganizations competed for the teams ' attention . Team leaders differed in their ability to inspire members to " run with " ideas and to motivate personnel outside the team to implement interventions . SUMMARY AND CONCLUSIONS Surveys and semi-structured interviews suggest that both the AD and CQI interventions involved complex social interactions that result ed in varied implementation across the different organizations . Final analyses will need to focus on identifying factors associated with the relative success or failure of both clinical change techniques OBJECTIVE : To assess the effect of a physician and pharmacist teamwork approach to uncontrolled hypertension in a medical resident teaching clinic , for patients who failed to meet the recommended goals of the fifth Joint National Commission on Detection , Evaluation and Treatment of High Blood Pressure . HYPOTHESIS : Physician and pharmacist teamwork can improve the rate of meeting national blood pressure goals in patients with previously uncontrolled hypertension . DESIGN : A single-blinded r and omized controlled trial lasting 6 months . SETTING : A primary care outpatient teaching clinic . PATIENTS : A sample of 95 adult hypertensive patients who failed to meet national blood pressure goals based on three consecutive visits over a 6-month period . INTERVENTION : Patients were r and omly assigned to a control arm of st and ard medical care or to an intervention arm in which a physician and pharmacist worked together as a team . MAIN RESULTS : At study completion , the percentage of patients achieving national goals due to intervention was more than double the percentage in the control arm ( 55 % vs 20 % , p < .001 ) . Systolic blood pressure declined 23 mm Hg in the intervention arm versus 11 mm Hg in the control arm ( p < .01 ) . Diastolic blood pressure declined 14 and 3 mm Hg in the intervention and control arms , respectively ( p < .001 ) . The intervention worked equally as well in men and women and demonstrated noticeable promise in a minority of mixed-ancestry Hawaiians in whom hypertension is of special concern . CONCLUSIONS : Patients who fail to achieve national blood pressure goals under st and ard outpatient medical care may benefit from a program that includes a physician and pharmacist teamwork approach Recent studies suggest that involving pharmacists is an effective strategy for improving patient adherence and blood pressure ( BP ) control . To date , few controlled studies have tested the cost-effectiveness of specific models for improving patient adherence and BP control in community pharmacies , where most Americans obtain prescriptions . We hypothesized that a team model of adherence monitoring and intervention in corporately owned community pharmacies can improve patient adherence , prescribing , and BP control among hypertensive black patients . The Team Education and Adherence Monitoring ( TEAM ) Trial is a r and omized controlled trial testing a multistep intervention for improving adherence monitoring and intervention in 28 corporately owned community pharmacies . Patients in the 14 control pharmacies received " usual care , " and patients in the 14 intervention pharmacies received TEAM Care by trained pharmacists and pharmacy technicians working with patients and physicians .  Data collectors screened 1250 patients and enrolled 597 hypertensive black patients . The primary end points were the proportion of patients achieving BP control and reductions in systolic and diastolic BP measured after 6 and 12 months . Secondary end points were changes in adherence monitoring and intervention , patient adherence and barriers to adherence , prescribing , and cost-effectiveness . Research ers also will examine potential covariates and barriers to change . Involving pharmacists is a potentially powerful means of improving BP control  in blacks . Pharmacists are in an excellent position to monitor patients between clinic visits and to provide useful information to patients and physicians OBJECTIVE To evaluate the effect of adding pharmacists to primary care teams on the management of hypertension and other cardiovascular risk factors  in patients with type 2 diabetes . RESEARCH DESIGN AND METHODS We conducted a r and omized controlled trial with blinded ascertainment of outcomes within primary care clinics in Edmonton , Canada .  Pharmacists performed medication assessment s and limited history and physical examinations and provided guideline -concordant recommendations to optimize medication management . Follow-up contact was completed as necessary . Control patients received usual care . The primary outcome was a ≥10 % decrease in systolic blood pressure at 1 year . RESULTS A total of 260 patients were enrolled , 57 % were women , the mean age was 59 years , diabetes duration was 6 years , and blood pressure was 129/74 mmHg . Forty-eight of 131 ( 37 % ) intervention patients and 30 of 129 ( 23 % ) control patients achieved the primary outcome ( odds ratio 1.9 [ 95 % CI 1.1–3.3 ] ; P = 0.02 ) . Among 153 patients with inadequately controlled hypertension at baseline , intervention patients ( n = 82 ) were significantly more likely than control patients ( n = 71 ) to achieve the primary outcome ( 41 [ 50 % ] vs. 20 [ 28 % ] ; 2.6 [ 1.3–5.0 ] ; P = 0.007 ) and recommended blood pressure targets ( 44 [ 54 % ] vs. 21 [ 30 % ] ; 2.8 [ 1.4–5.4 ] ; P = 0.003 ) . The 10-year risk of cardiovascular disease , based on changes to the UK Prospect i ve Diabetes Study Risk Engine , were predicted to decrease by 3 % for intervention patients and 1 % for control patients ( P = 0.005 ) . CONCLUSIONS Significantly more patients with type 2 diabetes achieved better blood pressure control  when pharmacists were added to primary care teams , which suggests that pharmacists can make important contributions to the primary care of these patients Background Given the increasing prevalence of diabetes and the lack of patients reaching recommended therapeutic goals , novel models of team-based care are emerging . These teams typically include a combination of physicians , nurses , case managers , pharmacists , and community-based peer health promoters ( HPs ) . Recent evidence supports the role of pharmacists in diabetes management to improve glycemic control , as they offer expertise in medication management with the ability to collaboratively intensify therapy . However , few studies of pharmacy-based models of care have focused on low income , minority population s that are most in need of intervention . Alternatively , HP interventions have focused largely upon low income minority groups , addressing their unique psychosocial and environmental challenges in diabetes self-care . This study will evaluate the impact of HPs as a complement to pharmacist management in a r and omized controlled trial . Methods / Design The primary aim of this r and omized trial is to evaluate the effectiveness of clinical pharmacists and HPs on diabetes behaviors ( including healthy eating , physical activity , and medication adherence ) , hemoglobin A1c , blood pressure , and LDL-cholesterol levels .  A total of 300 minority patients with uncontrolled diabetes from the University of Illinois Medical Center ambulatory network in Chicago will be r and omized to either pharmacist management alone , or pharmacist management plus HP support . After one year , the pharmacist-only group will be intensified by the addition of HP support and maintenance will be assessed by phasing out HP support from the pharmacist plus HP group ( crossover design ) . Outcomes will be evaluated at baseline , 6 , 12 , and 24 months . In addition , program and healthcare utilization data will be incorporated into cost and cost-effectiveness evaluations of pharmacist management with and without HP support . Discussion The study will evaluate an innovative , integrated approach to chronic disease management in minorities with poorly controlled diabetes . The approach is comprised of clinic-based pharmacists and community-based health promoters collaborating together . They will target patient-level factors ( e.g. , lack of adherence to lifestyle modification and medications ) and provider-level factors ( e.g. , clinical inertia ) that contribute to poor clinical outcomes in diabetes . Importantly , the study design and analytic approach will help determine the differential and combined impact of adherence to lifestyle changes , medication , and intensification on clinical outcomes .Trial registration Clinical Trials.gov identifier : PURPOSE The impact of pharmacist interventions on short-term clinical markers and long-term cardiovascular risk in patients with type 2 diabetes is investigated . METHODS Selected health outcomes were retrospectively analyzed in 147 adults with type 2 diabetes whose care was managed by a team of providers including a pharmacist ( the enhanced care group ) and a matched sample of patients ( n = 147 ) managed by a primary care physician only ( the control group ) . All patients received services through the same health maintenance organization ( HMO ) . The primary study endpoints were ( 1 ) the changes from baseline to 12-month follow-up in glycosylated hemoglobin ( HbA(1c ) ) , low-density lipoprotein cholesterol ( LDL-C ) , and blood pressure ( BP ) values , ( 2 ) rates of attainment of HbA(1c ) , LDL-C and BP goals , and ( 3 ) changes from baseline in predicted 10-year risks of coronary heart disease ( CHD ) and stroke . RESULTS During the 12-month study period , the mean HbA(1c ) value was decreased from 9.5 % to 6.9 % in the enhanced care group and from 9.3 % to 8.4 % in the control group ( p < 0.001 ) ; patients in the enhanced care group were significantly more likely to attain goals for HbA(1c ) ( odds ratio [ OR ] , 3.9 ) , LDL-C ( OR , 2.0 ) , and BP reduction ( OR , 2.0 ) and three times more likely to attain all three goals ( OR , 3.2 ) . The estimated 10-year risk of CHD was decreased from 16.4 % to 9.3 % with enhanced care versus a reduction from 17.4 % to 14.8 % with usual care ( p < 0.001 ) . CONCLUSION The addition of a pharmacist to an HMO primary care team improved short-term surrogate markers as well as long-term cardiovascular risk in adult patients with type 2 diabetes Abstract Agreement was reached with 12 acute medical and surgical wards/units at Sydney ’s Prince of Wales Hospital to participate in a trial of team nursing ( TN ) . Six units employed action research principles to undertake a change to a team nursing model and six remained with the pre-existing individual patient allocation ( IPA ) model . Task-based teaming was widely discarded by the team nursing units in favour of allocating patients within the team and introducing more supportive and communicative processes aim ed at fostering responsibility sharing . Localised team-based models of care arose in the change wards and were outlined , implemented and refined using social action research principles . A 12-month prospect i ve experimental comparison of job satisfaction and staff retention between the TN and IPA groups indicated statistically significant job satisfaction benefits and practically important staff retention benefits associated with moving away from an IPA model of nursing care delivery towards a team-based model of care delivery . Perhaps not surprisingly , job satisfaction gains were most marked among new graduate nurses , who reported real benefits from a teaming inspired shift in model of care in the acute inpatient environment Context Why do clinicians fail to intensify antihypertensive therapy when a patient 's blood pressure is elevated ? Contribution This study involved 1169 diabetic patients seen by 92 primary care providers at 9 Veterans Affairs facilities . All had elevated triage blood pressures , but only half received antihypertensive treatment intensification by providers . Patient reports of home blood pressures or repeated blood pressures by providers within normal limits and discussion of medication issues decreased the likelihood of antihypertensive intensification at clinic visits . Implication Uncertainty about true blood pressure values may underlie many reasons why physicians do not intensify antihypertensive therapy . The Editors Despite some recent improvements in blood pressure control , the number of patients with inadequate control remains high and contributes to excess morbidity and mortality , especially among patients at high risk from complications of hypertension ( 18 ) . Several studies have suggested that clinical inertiathe failure by providers to initiate or intensify therapy ( medication intensification ) in the face of apparent need to do sois a main contributor to poor control of hypertension ( 912 ) . Although the failure to intensify treatment medications for patients with elevated blood pressures at visits has been well documented ( 5 , 6 , 1218 ) , factors underlying what seems to be clinical inertia have been studied less systematic ally . When providers are queried after clinic visits about the lack of medication intensification for elevated blood pressure , they variously report that the patient 's true blood pressure was lower than the clinic blood pressure reading , that other patient concerns precluded attention on blood pressure management , and that patient adherence should be improved before medication intensification ( 6 , 17 ) . Some studies have examined the role of various clinical and patient factors in intensification decisions ( 6 , 8 , 17 , 19 , 20 ) , but no study has used a detailed conceptual model to comprehensively examine the relative contribution of a broad array of potential patient , provider , organizational , and visit-specific contributors to a medication intensification decision . In addition , although a frequently cited reason for deferring medication changes is that the clinic blood pressure does not reflect the patient 's true blood pressure ( 21 , 22 ) , this clinical uncertainty and its effects have not been explored . To better underst and factors underlying apparent clinical inertia for hypertension , we design ed the ABATe ( Addressing Barriers to Treatment for Hypertension ) study to examine treatment change decisions for diabetic primary care patients with elevated triage blood pressures  before a primary care visit . We defined elevated blood pressure for this population to be 140/90 mm Hg , a value well above guideline targets for diabetic patients and one clearly requiring some type of action ( 4 ) . Our goals were to assess how often patients presenting with an elevated triage blood pressure  received medication intensification or were scheduled for close follow-up and the role that clinical uncertainty about blood pressure , competing dem and s and prioritization , medication-related factors , and care organization play in treatment change decisions . Methods Conceptual Model On the basis of theories of patient , provider , and organization behavior ( 2336 ) , we developed a conceptual modelthe hypertension clinical action modelto examine decisions that drive treatment change ( medication intensification or prompt blood pressure follow-up ) for elevated blood pressure ( Figure 1 ) . The model , developed by 2 internists and 3 PhD-level method ologists in conjunction with development of ABATe and before data collection , proposes such treatment change decisions at a visit are based on 4 main conceptual domains : clinical uncertainty ( Is the patient 's blood pressure truly elevated ? Does the clinic blood pressure reflect the true blood pressure ? ) , competing dem and s and prioritization ( What other problems need to be addressed at this visit ? Is blood pressure management a priority for this particular patient ? Does the provider place priority on blood pressure management in general ? ) , medication-related factors ( Should adherence be addressed first ? Is the medication regimen too complex ? Will the patient accept another medication ? ) , and care organization ( Is there sufficient time to address hypertension ? Are staff available for follow-up ? ) . In addition , as part of grant development , we hypothesized that the following factors would lead to a lower probability of treatment change : uncertainty about whether the patient 's visit blood pressure reflected their true blood pressure ( clinical uncertainty ) , comorbid conditions unrelated to hypertension and diabetes ( 37 ) , a lower priority placed by the provider on the importance of treating elevated blood pressure , a higher number of baseline medications , perceived medication adherence problems , shorter clinic visit times , and lack of staff to follow up for blood pressure medication adjustment . Figure 1 . Hypertension clinical action model . Design Setting We conducted a prospect i ve cohort study of patients with scheduled primary care visits at 9 Veterans Affairs facilities located in 3 midwestern states . These facilities varied in size and structure , with 3 large academic-affiliated medical centers , 1 large nonacademic medical center , and 1 large and 4 small community-based outpatient clinics . From 15 February 2005 to 14 February 2006 , approximately 33500 diabetic patients visited primary care providers ( including residents ) in these facilities ( range per facility , 1050 to 9200 diabetic patients ) . The institutional review boards of all participating facilities approved the study protocol . Both patients and providers gave written informed consent before participating . Providers received a $ 50 bookstore gift card , and patients received a $ 10 department store gift card for completing initial surveys . Providers were told that the study was about diabetes and hypertension , with the purpose being to study challenges in treating patients with diabetes and ways to overcome these challenges so that quality of care can be enhanced . Primary Care Providers We invited all nonresident primary care providers with patient care responsibility at least 2 half-days per week to participate in the study . Of the eligible 126 providers approached , 104 consented to participate , for an overall recruitment rate of 83 % ( median facility-level recruitment rate , 88 % ) . By the time recruitment started , 12 providers had stopped working at their facility or changed their patient care responsibilities , leaving 92 primary care providers still eligible to participate ( range per facility , 2 to 28 providers ; median , 8) . Patients As specified by our institutional review board protocol s , potentially eligible patients were referred to study staff by triage personnel . During the enrollment periods at each facility , study staff screened all referred patients who presented for a scheduled visit to participating primary care providers and whose lowest triage systolic blood pressure was 140 mm Hg or greater or whose lowest triage diastolic blood pressure was 90 mm Hg or greater ( Figure 2 ) . In each of the facilities , triage staff routinely used an electronic cuff to check the patient 's blood pressure  before the provider visit . Triage policies specified that a second blood pressure measurement should be obtained if the first blood pressure was elevated . In addition to the triage blood pressure , study staff screened patients for the following inclusion criteria : the participant confirmed a diagnosis of diabetes , the participating provider was the primary provider of diabetes care for the participant , and the participant spoke English . Patients with impaired decision-making ability ( for example , dementia and traumatic brain injury ) or terminal disease and residents of nursing homes were excluded . Of the 1556 patients approached by study staff , 213 were ineligible ( Figure 2 ) and 1169 provided written informed consent to participate in the study ( approached and eligible , 87 % ; median facility-level recruitment rate , 89 % ) . We enrolled a median of 14 patients per provider ( range , 1 to 16 patients ) from February 2005 to March 2006 . Recruitment time per facility varied from 4 to 12 months . Figure 2 . Study flow diagram . PCP = primary care provider . * Diabetic patients presenting for a primary care visit to 1 of 92 participating providers were referred for eligibility assessment if their lowest triage blood pressure was140/90 mm Hg . * Number of responses varied by individual item . Our prespecified sample size calculations stipulated that we needed at least 11 patients from 80 physicians across 8 sites ( that is , 880 patients ) to detect a moderate difference in treatment change ( about 12 % ) when competing dem and s were or were not present . Data Sources We included data from 5 sources in our analysis ( Table 1 ) . First , a baseline survey completed by all providers provided variables assessing provider prioritization to blood pressure management , general provider characteristics , and availability of ancillary support for blood pressure management . Second , providers completed a brief visit survey for each patient after the same clinic session in which they saw the patient ( completion rate , 99 % ) . This survey provided information on which issues were discussed during the visit , the provider 's blood pressure goal for the patient , and whether medications were changed during the visit . Third , a patient survey conducted at enrollment provided sociodemographic characteristics , self-reported adherence and difficulty with medications , and self-management practice s ( completion rate , 91 % ) . Fourth , review of electronic medical records documented free text blood pressure values and notes on actions taken at the enrollment visit . Finally , patient age , prescribed medications and OBJECTIVE To evaluate the effect of teamwork ( physician and pharmacist ) on the management of uncontrolled hypertensive patients . METHODS This is a r and omized controlled clinical trial conducted from March to November 2009 . Patients attending the Family Medicine Clinic at Jordan University Hospital , Amman , Jordan with uncontrolled hypertension were invited to participate in the study . A total of 253 patients were r and omly allocated to an intervention ( n=130 ) or control group . In the intervention group , patients were managed by a physician-pharmacist team . In the control group , patients were managed by physician(s ) only . RESULTS In the intervention group , 79.4 % of patients achieved blood pressure ( BP ) goals specified by the Joint National Committee on Prevention and Management , Detection , Evaluation , and Treatment of High Blood Pressure ( JNC VII ) compared to 65.6 % in the control group ( p=0.01 ) . Decline in systolic BP was 16.1 + /- 14.6 mm Hg in the intervention group , and 10.6 + /- 13.5 mm Hg in the control group ( p=0.002 ) . Reduction in diastolic BP was 10.5 + /- 12.9 mm Hg in the intervention group , and 7.17 + /- 13.11 mm Hg in the control group , ( p=0.04 ) . Data were presented as mean + /- st and ard deviation . CONCLUSION This study found that the physician-pharmacist collaborative approach to uncontrolled hypertension in Jordan improved the rate of BP control in hypertensive patients , and result ed in more profound decline in both systolic and diastolic BP , and this will probably reflect on better outcomes in cardiovascular diseases . Establishing pharmaceutical care managed clinic in the setting of outpatient-clinics is possible , and provides better management of patients CONTEXT Treating hypertension decreases mortality and disability from cardiovascular disease , but most hypertension remains inadequately controlled . OBJECTIVE To determine if a new model of care that uses patient Web services , home blood pressure ( BP ) monitoring , and pharmacist-assisted care improves BP control . DESIGN , SETTING , AND PARTICIPANTS A 3-group r and omized controlled trial , the Electronic Communications and Home Blood Pressure Monitoring study was based on the Chronic Care Model . The trial was conducted at an integrated group practice in Washington state , enrolling 778 participants aged 25 to 75 years with uncontrolled essential hypertension and Internet access . Care was delivered over a secure patient Web site from June 2005 to December 2007 . INTERVENTIONS Participants were r and omly assigned to usual care , home BP monitoring and secure patient Web site training only , or home BP monitoring and secure patient Web site training plus pharmacist care management delivered through Web communications . MAIN OUTCOME MEASURES Percentage of patients with controlled BP ( < 140/90 mm Hg ) and changes in systolic and diastolic BP at 12 months . RESULTS Of 778 patients , 730 ( 94 % ) completed the 1-year follow-up visit . Patients assigned to the home BP monitoring and Web training only group had a nonsignificant increase in the percentage of patients with controlled BP ( < 140/90 mm Hg ) compared with usual care ( 36 % [ 95 % confidence interval { CI } , 30%-42 % ] vs 31 % [ 95 % CI , 25%-37 % ] ; P = .21 ) . Adding Web-based pharmacist care to home BP monitoring and Web training significantly increased the percentage of patients with controlled BP ( 56 % ; 95 % CI , 49%-62 % ) compared with usual care ( P < .001 ) and home BP monitoring and Web training only ( P < .001 ) . Systolic BP was decreased stepwise from usual care to home BP monitoring and Web training only to home BP monitoring and Web training plus pharmacist care . Diastolic BP was decreased only in the pharmacist care group compared with both the usual care and home BP monitoring and Web training only groups . Compared with usual care , the patients who had baseline systolic BP of 160 mm Hg or higher and received home BP monitoring and Web training plus pharmacist care had a greater net reduction in systolic BP ( -13.2 mm Hg [ 95 % CI , -19.2 to -7.1 ] ; P < .001 ) and diastolic BP ( -4.6 mm Hg [ 95 % CI , -8.0 to -1.2 ] ; P < .001 ) , and improved BP control ( relative risk , 3.32 [ 95 % CI , 1.86 to 5.94 ] ; P<.001 ) . CONCLUSION Pharmacist care management delivered through secure patient Web communications improved BP control  in patients with hypertension . Trial Registration clinical trials.gov Identifier : NCT00158639 OBJECTIVE To compare the effectiveness of an evidence -based , systematic approach to hypertension care involving comanagement of patients by primary care physicians and clinical pharmacists versus usual care in reducing blood pressure in patients with uncontrolled hypertension . METHODS Patients in a staff model medical group with uncontrolled hypertension were r and omized to either a usual care ( UC ) or a physician-pharmacist comanagement ( PPCM ) group . All physicians in the study received both group and individual education and participated in the development of an evidence -based hypertension treatment algorithm . Physicians were then given the names of their patients whose medical records documented elevated blood pressures ( defined as systolic > or = 140 mm Hg and /or diastolic > or = 90 mm Hg for patients aged < 65 yrs , and systolic > or = 160 mm Hg and /or diastolic > or = 90 mm Hg for those aged > or = 65 yrs ) . Patients r and omized to the UC group were managed by primary care physicians alone . Those r and omized to the PPCM group were comanaged by their primary care physician and a clinical pharmacist , who provided patient education , made treatment recommendations , and provided follow-up .  Blood pressure measurements , antihypertensive drugs , and visit costs/patient were obtained from medical records . RESULTS One hundred ninety-seven patients with uncontrolled hypertension participated in the study . Both PPCM and UC groups experienced significant reductions in blood pressure ( systolic -22 and -11 mm Hg , respectively , p < 0.01 ; diastolic -7 and -8 mm Hg , respectively , p < 0.01 ) . The reduction in systolic blood pressure was greater in the PPCM group after adjusting for differences in baseline blood pressure between the groups ( p < 0.01 ) . More patients achieved blood pressure control in the PPCM than in the UC group ( 60 % vs 43 % , p = 0.02 ) . Average provider visit costs/patient were higher in the UC than the PPCM group ( $ 195 vs $ 160 , p = 0.02 ) . CONCLUSIONS An evidence -based , systematic approach using physician-pharmacist comanagement for patients with uncontrolled hypertension result ed in improved blood pressure control and reduced average visit costs/patient There is evidence for a team-based approach in the management of chronic disease in primary health care . However , the st and ard of care is variable , probably reflecting the limited organisational capacity of health services to provide the necessary structured and organised care for this group of patients . This study aim ed to evaluate the impact of a structured intervention involving non-GP staff in GP practice s  on the quality of care for patients with diabetes or cardiovascular disease . A cluster r and omised trial was undertaken across 60 GP practice s. The intervention was implemented in 30 practice s with staff and patients interviewed at baseline and at 12 - 15 months follow up . The change in team roles was evaluated using a  question naire completed by practice staff . The quality of care was evaluated using the Patient Assessment of Chronic Illness Care question naire . We found that although the team roles of staff improved in the intervention practice s and there were significant differences between practice s , there was no significant difference between those in the intervention and control groups in patient-assessed quality of care after adjusting for baseline-level score and covariates at the 12-month follow up . Practice team roles were not significantly associated with change in Patient Assessment of Chronic Illness Care scores .  Patients with multiple conditions were more likely to assess their quality of care to be better . Thus , although previous research has shown a cross-sectional association between team work and quality of care , we were unable to replicate these findings in the present study . These results may be indicative of insufficient time for organisational change to result in improved patient-assessed quality of care , or because non-GP staff roles were not sufficiently focussed on the aspects of care assessed . The findings provide important information for research ers when design ing similar studies Complex interventions , which have been shown to improve primary care depression outcomes , are difficult to disseminate to routine practice setting s. To address this problem , we developed a brief intervention to train primary care physicians and nurses employed by the practice to improve the detection and management of major depression . Before recruitment began , the research team conducted academic detailing conference calls with primary care physicians and nurses , and provided in-person training with nurses and administrative staff . Administrative staff screened over 11,000 patients before their visits to identify those with probable major depression . Primary care physicians delegated increased responsibility to office nurses , who educated over 90 % of patients about effective depression treatment and systematic ally monitored their progress over time . Early results demonstrate that community primary care practice s can rebundle traditional team roles over the short-term to provide more systematic mental health treatment without adding additional personnel . A rigorous evaluation of this effort will reduce time-consuming , expensive , and often unsuccessful efforts to " translate " research intervention findings into everyday practice BACKGROUND Improving the quality and efficiency of chronic disease care is an important goal . OBJECTIVE To test whether patients with chronic disease working with lay " care guides "  would achieve more evidence -based goals than those receiving usual care . DESIGN Parallel-group r and omized trial , stratified by clinic and conducted from July 2010 to April 2012 . Patients were assigned in a 2:1 ratio to a care guide or usual care . Patients , providers , and persons assessing outcomes were not blinded to treatment assignment . ( Clinical Trials.gov : NCT01156974 ) . SETTING 6 primary care clinics in Minnesota . PATIENTS Adults with hypertension , diabetes , or heart failure . INTERVENTION 2135 patients were given  disease-specific information about st and ard care goals and asked to work toward goals for 1 year , with or without the help of a care guide . Care guides were 12 laypersons who received brief training about these diseases and behavior change . MEASUREMENTS The primary end point for each patient was change in percentage of goals met 1 year after enrollment . RESULTS The percentage of goals met increased in both the care guide and usual care groups ( changes from baseline , 10.0 % and 3.9 % , respectively ) . Patients with care guides achieved more goals than usual care patients ( 82.6 % vs. 79.1 % ; odds ratio , 1.31 [ 95 % CI , 1.16 to 1.47 ] ; P < 0.001 ) ; reduced unmet goals by 30.1 % compared with 12.6 % for usual care patients ; and improved more than usual care patients in meeting several individual goals , including not using tobacco . Estimated cost was $ 286 per patient per year . LIMITATIONS Providers ' usual care may have been influenced by contact with care guides . Last available data in the electronic health record were used to assess end points . CONCLUSION Adding care guides to the primary care team can improve care for some patients with chronic disease at low cost It is important to underst and the effects of a new care model on health professionals ' satisfaction , which may help inform organizations ' decisions regarding the adoption of the model . This study evaluates the effect of the Guided Care model of primary care on physicians ' , Guided Care Nurses ' and practice staff satisfaction with processes of care for chronically ill older patients . In Guided Care , a specially educated registered nurse works with 2 - 5 primary care physicians , performing 8 clinical activities for 50 - 60 chronically ill older patients . This model was tested in a 3-year matched-pair cluster-r and omized controlled trial with 14 pods ( teams of physicians and staff ) r and omly assigned , within pairs , to provide Guided Care or usual care . Physicians and Guided Care Nurses were surveyed at baseline and annually for 3 years . Staff were surveyed at baseline and 2 years later . Physicians ' satisfaction with chronic care processes , knowledge of patients , and care coordination were measured , as well as Guided Care Nurses ' satisfaction with chronic care processes and staff perceptions of quality of care . Findings suggest that Guided Care improved physician satisfaction with patient/family communication and management of chronic care , and it may bolster staff beliefs that care is patient oriented . Differences in other aspects of care were not statistically significant PURPOSE To determine whether the type of health care provider ( i.e. , physician versus physician-nurse team ) affected the quality of hypertension care given to two groups of r and omly selected adult women . DATA SOURCES Three indicators measured the quality of hypertension care : blood pressure control level , knowledge of hypertension , and discussion about blood pressure medications with the health care provider(s ) .  Blood pressure readings were taken with a 24-hr ambulatory blood pressure monitor , and demographic data from survey results taken at orientation and research er-collected data on posttreatment knowledge of hypertension and cognitive representations of hypertension were gathered . Chi-square and t tests were used to analyze the data . CONCLUSIONS The group whose care was managed by a physician-nurse team demonstrated lower means for 24-hr systolic blood pressure and diastolic blood pressure ( systolic : M = 132 , SD = 14.9 ; diastolic : M = 75 , SD = 11.3 ) than the group whose care was managed only by one or more physicians ( systolic : M = 136 , SD = 13.4 ; diastolic : M = 79 , SD = 11.24 ) . Also , the group whose care was managed by a physician-nurse team revealed significantly higher scores for discussion of blood pressure medication than the group whose care was managed only by one or more physicians . There were no group differences for knowledge of hypertension . IMPLICATION S FOR PRACTICE Nurses qualified to assist with meeting the needs of hypertension clients in primary care setting s can positively affect clients ' knowledge about blood pressure medication and --perhaps as a result of this knowledge -- how well the clients control their blood pressure Background — Hypertension control rates remain suboptimal . Pharmacists ’ scope of practice is evolving , and their position in the community may be ideal for improving hypertension care . We aim ed to study the impact of pharmacist prescribing on blood pressure ( BP ) control in community-dwelling patients . Methods and Results — We design ed a patient-level , r and omized , controlled trial , enrolling adults with above-target BP ( as defined by Canadian guidelines ) through community pharmacies , hospitals , or primary care teams in 23 communities in Alberta . Intervention group patients received an assessment of BP and cardiovascular risk , education on hypertension , prescribing of antihypertensive medications , laboratory monitoring , and monthly follow-up visits for 6 months ( all by their pharmacist ) . Control group patients received a wallet card for BP recording , written hypertension information , and usual care from their pharmacist and physician . Primary outcome was the change in systolic BP at 6 months . A total of 248 patients ( mean age , 64 years ; 49 % male ) were enrolled .  Baseline mean±SD systolic/diastolic BP was 150±14/84±11 mm Hg . The intervention group had a mean±SE reduction in systolic BP at 6 months of 18.3±1.2 compared with 11.8±1.9 mm Hg in the control group , an adjusted difference of 6.6±1.9 mm Hg ( P=0.0006 ) . The adjusted odds of patients achieving BP targets was 2.32 ( 95 % confidence interval , 1.17–4.15 in favor of the intervention ) . Conclusions — Pharmacist prescribing for patients with hypertension result ed in a clinical ly important and statistically significant reduction in BP . Policy makers should consider an exp and ed role for pharmacists , including prescribing , to address the burden of hypertension . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00878566 Background —Despite well-publicized guidelines on the appropriate management of cardiovascular disease and type 2 diabetes , the implementation of risk-reducing practice s remains poor . This report describes the results of a r and omized , controlled clinical trial evaluating the effectiveness of a comprehensive program of cardiovascular disease risk reduction delivered by nurse practitioner /community health worker ( NP/CHW ) teams versus enhanced usual care ( EUC ) to improve lipids , blood pressure , glycated hemoglobin ( HbA1c ) , and patient perceptions of the quality of their chronic illness care in patients in urban community health centers . Methods and Results —A total of 525 patients with documented cardiovascular disease , type 2 diabetes , hypercholesterolemia , or hypertension and levels of LDL cholesterol , blood pressure , or HbA1c that exceeded goals established by national guidelines were r and omly assigned to NP/CHW ( n=261 ) or EUC ( n=264 ) groups . The NP/CHW intervention included aggressive pharmacological management and tailored educational and behavioral counseling for lifestyle modification and problem solving to address barriers to adherence and control . Compared with EUC , patients in the NP/CHW group had significantly greater 12-month improvement in total cholesterol ( difference , 19.7 mg/dL ) , LDL cholesterol ( difference,15.9 mg/dL ) , triglycerides ( difference , 16.3 mg/dL ) , systolic blood pressure ( difference , 6.2 mm Hg ) , diastolic blood pressure ( difference , 3.1 mm Hg ) , HbA1c ( difference , 0.5 % ) , and perceptions of the quality of their chronic illness care ( difference , 1.2 points ) . Conclusions —An intervention delivered by an NP/CHW team using individualized treatment regimens based on treat-to-target algorithms can be an effective approach to improve risk factor status and perceptions of chronic illness care in high-risk patients . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT00241904
Team-based care increased the proportion of people with controlled BP  and reduced both systolic and diastolic BP , especially when pharmacists and nurses were part of the team .
CONTEXT Uncontrolled hypertension remains a widely prevalent cardiovascular risk factor in the U.S. team-based care , established by adding new staff or changing the roles of existing staff such as nurses and pharmacists to work with a primary care provider and the patient .
Team-based care has the potential to improve the quality of hypertension management .
The goal of this Community Guide systematic review was to examine the effectiveness of team-based care in improving blood pressure ( BP ) outcomes .