CHICAGO, IL — A community-based pharmacist intervention in Alberta,
Canada—where authorized pharmacists can prescribe and adjust medications
and doses—reduced the estimated risk for cardiovascular events by
21% in 3 months
[1].
These benefits were seen in the
RxEACH
study of 700 high-risk patients who had at least one uncontrolled
risk factor (hypertension, hyperglycemia, hyperlipidemia, smoking) and
were randomized to usual pharmacist care or a targeted intervention
designed to lower CVD risk.
Dr Ross T Tsuyuki (University of Alberta, Edmonton) presented these findings in a clinical research session at the
American College of Cardiology (ACC) 2016 Scientific Sessions, and the paper was simultaneously published in the
Journal of the American College of Cardiology.
"We
think [this] represents a new paradigm of community-based
cardiovascular risk reduction," he said, adding that patients like the
intervention and stressing that it involves close collaboration
their family-care physicians.
"Engaging pharmacists could bring
another 450,000 'helping hands' in the United States and Canada to help
reduce the burden of cardiovascular disease," according to Tsuyuki
and colleagues. "We would encourage policy makers to consider broadening
the scope of practice of pharmacists (as in Alberta) and for
pharmacists and pharmacy professional organizations to seize these
opportunities for the betterment of patient care," they conclude.
Session
panelist Dr Allen J Taylor (MedStar Georgetown University Hospital and
MedStar Washington Hospital Center, Washington, DC) told
heartwire
from Medscape that the results have to be
interpreted with caution, because risk score calculators such as
Framingham are based on long-term exposure to risks, and this was a
3-month study.
Nevertheless, the researchers looked at four risk
factors and "were able to make a fair amount of changes across the
board, [which] is laudable," he said. "There's a physician shortage,
and there's no reason why we can't rely upon the pharmacist as part of
the healthcare team to deliver more prevention," according to
Taylor.
Community pharmacists are accessible, frontline healthcare
professionals who often see patients with or at high risk for CVD, and
prior studies have shown that
this can be effective in managing certain CVD risk factors, Tsuyuki noted.
RxEACH
evaluated how a comprehensive, provincewide, pharmacist-delivered
intervention designed to improve four risk factors (diabetes,
hypertension, hyperlipidemia, and smoking) would affect predicted
risk of a CVD event.
In 2014 and 2015, pharmacists in 56 practices
in Alberta identified and randomized 723 adults aged 18 and older who
had diabetes, chronic kidney disease, cerebrovascular disease,
cardiovascular disease, peripheral artery disease, or multiple risk
factors and a Framingham risk score >20%.
The patients also had
to have at least one uncontrolled risk factor (blood pressure
>140/90 mm Hg or >130/80 mm Hg if diabetic, LDL cholesterol
>2.0 mmol/L, HbA
1c >7%, or current smoker).
The
researchers randomized 353 patients to usual care and 370 patients to
the intervention. The patients had a mean age of 62, 58% were male, and
their mean estimated risk of a CV event was 26%.
A fair number of patients had diabetes, vascular disease, and
coronary heart disease, and a relatively small group [7%] were
primary-prevention patients," Tsuyuki noted. Many patients (72%) had
poorly controlled blood pressure, 59% had poorly controlled
dyslipidemia, 27% were smokers, and 79% of the patients with
diabetes had poor glycemic control.
Patients in the intervention
group received a medication-therapy-management consultation with their
pharmacist, in which the pharmacist measured their blood pressure,
waist circumference, height, and weight; ordered laboratory tests to
determine HbA
1c, lipid levels, and kidney function; and
discussed CVD risk factors and their specific CVD risk scores
(calculated from risk engines such as the UKPDS, the international
score, and the Framingham risk score).
The pharmacists saw the
patients in the intervention group every 3 to 4 weeks for 3 months,
adjusted medications and doses based on Canadian clinical practice
guidelines, and relayed information to the patient's physician after
each patient contact. "Pharmacists did adjust doses, but more often they
added drugs or discontinued drugs that weren't working," Tsuyuki
noted.
At 3 months, the patients' estimated cardiovascular disease
risk was virtually unchanged in the usual-care group, but it dropped
from 25.5% to 20.5% in the pharmacist-intervention group.
Patients
in the intervention group were more likely to achieve
guideline-recommended targets for LDL cholesterol (55.5% vs 45.6%),
blood pressure (50.9% vs 27.8%), and HbA
1c (42.2% vs 24.6%), and more likely to not smoke.
In
the intervention group, mean blood pressure decreased from 137/81 mm Hg
to 127/77 mm Hg; mean LDL cholesterol decreased from 2.47 mmol/L to
2.07 mmol/L; mean HbA
1c dropped from 8.61% to 7.60%; and
the number who smoked fell from 26.2% to 19.7%, but these measures
remained unchanged in the control group.
Compared with
patients in the control group, those in the intervention group had a
0.2-mmol/L greater reduction in LDL cholesterol, a 9.37-mm-Hg greater
reduction in systolic blood pressure, a 0.92% greater reduction in HbA
1c, and there were 20.2% fewer smokers (all
P<0.0001).
Panelist Dr Prediman K Shah (Cedars Sinai
Medical Center, West Hollywood, CA) wanted to know if all pharmacists in
Canada can prescribe medications or change doses. In some places in the
United States, there are
collaborative drug-therapy management programs
with pharmacists and physicians, Tsuyuki noted, but Alberta is the
only Canadian province with this broadly expanded scope of pharmacist
practice.
That the number of smokers in the intervention group
dropped by 20% in 3 months is "really rather remarkable," Taylor noted.
The pharmacists "are not just providing pills, they are providing
general health advice, and you can only imagine what they could do if
they built in things like adherence and monitoring, exercise
recommendations, dietary recommendations. . . . It's turning the
interaction at a pharmacy window, which used to be to simply sliding a
prescription in one direction and pills coming back in the other
direction, to an actual healthcare interaction. 'Are you taking your
medications? What are your risk factors? What numbers have you
achieved?' "
Funding for the RxEACH study was
provided by Alberta Health, the Cardiovascular Health and Stroke
Strategic Clinical Network of Alberta Health Services, and Merck
Canada (for development of the educational materials only). Tsuyuki
received investigator-initiated research grants from Merck, Sanofi, and
AstraZeneca and is a consultant for Merck; the coauthors have no
relevant financial relationships. Taylor reports receiving consultant
fees/honoraria from Amgen and Eli Lilly and being on the
speaker's bureau of Sanofi.
Many
patients who are at risk for cardiovascular disease (CVD) do not
receive optimal counseling, medication, and monitoring. Several smaller
studies have shown that using clinical pharmacists to administer
risk-reduction strategies for individual CVD risk factors is effective.
Now, in a large, community-based, Canadian study, researchers assessed
the effect of a pharmacist-administered medication therapy management
program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled
CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with
diabetes, 27% smokers) and received care from 56 pharmacies in Alberta.
Patients were randomized to usual care or to a protocol of care
provided directly by pharmacists that included baseline clinical and
risk-factor assessment, validated calculation of CVD risk, counseling
and education, guideline-based new or revised prescriptions, and monthly
monitoring for 3 months. All care was communicated to patients' family
physicians, and pharmacists billed for their services.
Mean
baseline 10-year risks for CVD were 25.6% in the intervention group and
26.6% in the usual-care group. At 3 months, mean recalculated risk in
the intervention group was 20.5%, versus 25.9% in the usual-care group —
a significant difference. Significantly more patients in the
intervention group than in the usual-care group achieved prespecified
goals for each assessed risk factor, including an absolute difference of
7% in smoking-cessation rates. No adverse events were reported.
-
See more at:
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Many
patients who are at risk for cardiovascular disease (CVD) do not
receive optimal counseling, medication, and monitoring. Several smaller
studies have shown that using clinical pharmacists to administer
risk-reduction strategies for individual CVD risk factors is effective.
Now, in a large, community-based, Canadian study, researchers assessed
the effect of a pharmacist-administered medication therapy management
program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled
CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with
diabetes, 27% smokers) and received care from 56 pharmacies in Alberta.
Patients were randomized to usual care or to a protocol of care
provided directly by pharmacists that included baseline clinical and
risk-factor assessment, validated calculation of CVD risk, counseling
and education, guideline-based new or revised prescriptions, and monthly
monitoring for 3 months. All care was communicated to patients' family
physicians, and pharmacists billed for their services.
Mean
baseline 10-year risks for CVD were 25.6% in the intervention group and
26.6% in the usual-care group. At 3 months, mean recalculated risk in
the intervention group was 20.5%, versus 25.9% in the usual-care group —
a significant difference. Significantly more patients in the
intervention group than in the usual-care group achieved prespecified
goals for each assessed risk factor, including an absolute difference of
7% in smoking-cessation rates. No adverse events were reported.
-
See more at:
http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf
Longer-term studies are warranted to assess clinical outcomes.
Many
patients who are at risk for cardiovascular disease (CVD) do not
receive optimal counseling, medication, and monitoring. Several smaller
studies have shown that using clinical pharmacists to administer
risk-reduction strategies for individual CVD risk factors is effective.
Now, in a large, community-based, Canadian study, researchers assessed
the effect of a pharmacist-administered medication therapy management
program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled
CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with
diabetes, 27% smokers) and received care from 56 pharmacies in Alberta.
Patients were randomized to usual care or to a protocol of care
provided directly by pharmacists that included baseline clinical and
risk-factor assessment, validated calculation of CVD risk, counseling
and education, guideline-based new or revised prescriptions, and monthly
monitoring for 3 months. All care was communicated to patients' family
physicians, and pharmacists billed for their services.
Mean
baseline 10-year risks for CVD were 25.6% in the intervention group and
26.6% in the usual-care group. At 3 months, mean recalculated risk in
the intervention group was 20.5%, versus 25.9% in the usual-care group —
a significant difference. Significantly more patients in the
intervention group than in the usual-care group achieved prespecified
goals for each assessed risk factor, including an absolute difference of
7% in smoking-cessation rates. No adverse events were reported.
- See more at:
http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf
Longer-term studies are warranted to assess clinical outcomes.
Many
patients who are at risk for cardiovascular disease (CVD) do not
receive optimal counseling, medication, and monitoring. Several smaller
studies have shown that using clinical pharmacists to administer
risk-reduction strategies for individual CVD risk factors is effective.
Now, in a large, community-based, Canadian study, researchers assessed
the effect of a pharmacist-administered medication therapy management
program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled
CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with
diabetes, 27% smokers) and received care from 56 pharmacies in Alberta.
Patients were randomized to usual care or to a protocol of care
provided directly by pharmacists that included baseline clinical and
risk-factor assessment, validated calculation of CVD risk, counseling
and education, guideline-based new or revised prescriptions, and monthly
monitoring for 3 months. All care was communicated to patients' family
physicians, and pharmacists billed for their services.
Mean
baseline 10-year risks for CVD were 25.6% in the intervention group and
26.6% in the usual-care group. At 3 months, mean recalculated risk in
the intervention group was 20.5%, versus 25.9% in the usual-care group —
a significant difference. Significantly more patients in the
intervention group than in the usual-care group achieved prespecified
goals for each assessed risk factor, including an absolute difference of
7% in smoking-cessation rates. No adverse events were reported.
- See more at:
http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf
Longer-term studies are warranted to assess clinical outcomes.
Many
patients who are at risk for cardiovascular disease (CVD) do not
receive optimal counseling, medication, and monitoring. Several smaller
studies have shown that using clinical pharmacists to administer
risk-reduction strategies for individual CVD risk factors is effective.
Now, in a large, community-based, Canadian study, researchers assessed
the effect of a pharmacist-administered medication therapy management
program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled
CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with
diabetes, 27% smokers) and received care from 56 pharmacies in Alberta.
Patients were randomized to usual care or to a protocol of care
provided directly by pharmacists that included baseline clinical and
risk-factor assessment, validated calculation of CVD risk, counseling
and education, guideline-based new or revised prescriptions, and monthly
monitoring for 3 months. All care was communicated to patients' family
physicians, and pharmacists billed for their services.
Mean
baseline 10-year risks for CVD were 25.6% in the intervention group and
26.6% in the usual-care group. At 3 months, mean recalculated risk in
the intervention group was 20.5%, versus 25.9% in the usual-care group —
a significant difference. Significantly more patients in the
intervention group than in the usual-care group achieved prespecified
goals for each assessed risk factor, including an absolute difference of
7% in smoking-cessation rates. No adverse events were reported.
At
the time that NEJM Journal Watch reviewed this article, its publisher
noted that it was an accepted manuscript and that subsequent changes
could be made.
Editor Disclosures at Time of Publication
- See more at:
http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf
Longer-term studies are warranted to assess clinical outcomes.
Many
patients who are at risk for cardiovascular disease (CVD) do not
receive optimal counseling, medication, and monitoring. Several smaller
studies have shown that using clinical pharmacists to administer
risk-reduction strategies for individual CVD risk factors is effective.
Now, in a large, community-based, Canadian study, researchers assessed
the effect of a pharmacist-administered medication therapy management
program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled
CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with
diabetes, 27% smokers) and received care from 56 pharmacies in Alberta.
Patients were randomized to usual care or to a protocol of care
provided directly by pharmacists that included baseline clinical and
risk-factor assessment, validated calculation of CVD risk, counseling
and education, guideline-based new or revised prescriptions, and monthly
monitoring for 3 months. All care was communicated to patients' family
physicians, and pharmacists billed for their services.
Mean
baseline 10-year risks for CVD were 25.6% in the intervention group and
26.6% in the usual-care group. At 3 months, mean recalculated risk in
the intervention group was 20.5%, versus 25.9% in the usual-care group —
a significant difference. Significantly more patients in the
intervention group than in the usual-care group achieved prespecified
goals for each assessed risk factor, including an absolute difference of
7% in smoking-cessation rates. No adverse events were reported.
At
the time that NEJM Journal Watch reviewed this article, its publisher
noted that it was an accepted manuscript and that subsequent changes
could be made.
Editor Disclosures at Time of Publication
- See more at:
http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf
Community-Based Pharmacist Program Can Lower Cardiovascular Risk
Longer-term studies are warranted to assess clinical outcomes.
Many
patients who are at risk for cardiovascular disease (CVD) do not
receive optimal counseling, medication, and monitoring. Several smaller
studies have shown that using clinical pharmacists to administer
risk-reduction strategies for individual CVD risk factors is effective.
Now, in a large, community-based, Canadian study, researchers assessed
the effect of a pharmacist-administered medication therapy management
program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled
CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with
diabetes, 27% smokers) and received care from 56 pharmacies in Alberta.
Patients were randomized to usual care or to a protocol of care
provided directly by pharmacists that included baseline clinical and
risk-factor assessment, validated calculation of CVD risk, counseling
and education, guideline-based new or revised prescriptions, and monthly
monitoring for 3 months. All care was communicated to patients' family
physicians, and pharmacists billed for their services.
Mean
baseline 10-year risks for CVD were 25.6% in the intervention group and
26.6% in the usual-care group. At 3 months, mean recalculated risk in
the intervention group was 20.5%, versus 25.9% in the usual-care group —
a significant difference. Significantly more patients in the
intervention group than in the usual-care group achieved prespecified
goals for each assessed risk factor, including an absolute difference of
7% in smoking-cessation rates. No adverse events were reported.
At
the time that NEJM Journal Watch reviewed this article, its publisher
noted that it was an accepted manuscript and that subsequent changes
could be made.
Editor Disclosures at Time of Publication
- See more at:
http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf
Community-Based Pharmacist Program Can Lower Cardiovascular Risk
Longer-term studies are warranted to assess clinical outcomes.
Many
patients who are at risk for cardiovascular disease (CVD) do not
receive optimal counseling, medication, and monitoring. Several smaller
studies have shown that using clinical pharmacists to administer
risk-reduction strategies for individual CVD risk factors is effective.
Now, in a large, community-based, Canadian study, researchers assessed
the effect of a pharmacist-administered medication therapy management
program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled
CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with
diabetes, 27% smokers) and received care from 56 pharmacies in Alberta.
Patients were randomized to usual care or to a protocol of care
provided directly by pharmacists that included baseline clinical and
risk-factor assessment, validated calculation of CVD risk, counseling
and education, guideline-based new or revised prescriptions, and monthly
monitoring for 3 months. All care was communicated to patients' family
physicians, and pharmacists billed for their services.
Mean
baseline 10-year risks for CVD were 25.6% in the intervention group and
26.6% in the usual-care group. At 3 months, mean recalculated risk in
the intervention group was 20.5%, versus 25.9% in the usual-care group —
a significant difference. Significantly more patients in the
intervention group than in the usual-care group achieved prespecified
goals for each assessed risk factor, including an absolute difference of
7% in smoking-cessation rates. No adverse events were reported.
At
the time that NEJM Journal Watch reviewed this article, its publisher
noted that it was an accepted manuscript and that subsequent changes
could be made.
Editor Disclosures at Time of Publication
- See more at:
http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf
Community-Based Pharmacist Program Can Lower Cardiovascular Risk
Longer-term studies are warranted to assess clinical outcomes.
Many
patients who are at risk for cardiovascular disease (CVD) do not
receive optimal counseling, medication, and monitoring. Several smaller
studies have shown that using clinical pharmacists to administer
risk-reduction strategies for individual CVD risk factors is effective.
Now, in a large, community-based, Canadian study, researchers assessed
the effect of a pharmacist-administered medication therapy management
program in 723 high-risk patients (mean age, 62) who had ≥1 uncontrolled
CVD risk factor (84% with hypertension, 83% with dyslipidemia, 79% with
diabetes, 27% smokers) and received care from 56 pharmacies in Alberta.
Patients were randomized to usual care or to a protocol of care
provided directly by pharmacists that included baseline clinical and
risk-factor assessment, validated calculation of CVD risk, counseling
and education, guideline-based new or revised prescriptions, and monthly
monitoring for 3 months. All care was communicated to patients' family
physicians, and pharmacists billed for their services.
Mean
baseline 10-year risks for CVD were 25.6% in the intervention group and
26.6% in the usual-care group. At 3 months, mean recalculated risk in
the intervention group was 20.5%, versus 25.9% in the usual-care group —
a significant difference. Significantly more patients in the
intervention group than in the usual-care group achieved prespecified
goals for each assessed risk factor, including an absolute difference of
7% in smoking-cessation rates. No adverse events were reported.
At
the time that NEJM Journal Watch reviewed this article, its publisher
noted that it was an accepted manuscript and that subsequent changes
could be made.
Editor Disclosures at Time of Publication
- See more at:
http://www.jwatch.org/na40995/2016/04/12/community-based-pharmacist-program-can-lower?ijkey=MsNHBBKwUzQXs&keytype=ref&siteid=jwatch&query=pfw&jwd=000012895000&jspc=&variant=full-text#sthash.DFk0t5TM.dpuf
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