The benefits of physician-pharmacist collaboration

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Applied Evidence

The benefits of physician-pharmacist collaboration

J Fam Pract. 2017 December;66(12):E1-E8

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References

1. Borenstein JE, Graber G, Saltiel E, et al. Physician-pharmacist comanagement of hypertension: a randomized, comparative trial. Pharmacotherapy. 2003;23:209-216.

2. Hunt JS, Siemienczuk J, Pape G, et al. A randomized controlled trial of team-based care: impact of physician-pharmacist collaboration on uncontrolled hypertension. J Gen Intern Med. 2008;23:1966-1972.

3. Carter BL, Bergus GR, Dawson JD, et al. A cluster randomized trial to evaluate physician/pharmacist collaboration to improve blood pressure control. J Clin Hypertens (Greenwich). 2008;10:260-271.

4. Carter BL, Ardery G, Dawson JD, et al. Physician and pharmacist collaboration to improve blood pressure control. Arch Intern Med. 2009;169:1996-2002.

5. Weber CA, Ernst ME, Sezate GS, et al. Pharmacist-physician comanagement of hypertension and reduction in 24-hour ambulatory blood pressures. Arch Intern Med. 2010;170:1634-1639.

6. Hirsch JD, Steers N, Adler DS, et al. Primary care-based, pharmacist-physician collaborative medication-therapy management of hypertension: a randomized, pragmatic trial. Clin Ther. 2014;36:1244-1254.

7. Carter BL, Coffey CS, Ardery G, et al. Cluster-randomized trial of a physician/pharmacist collaborative model to improve blood pressure control. Circ Cardiovasc Qual Outcomes. 2015;8:235-243.

8. Sisson EM, Dixon DL, Kildow DC, et al. Effectiveness of a pharmacist-physician team-based collaboration to improve long-term blood pressure control at an inner-city safety-net clinic. Pharmacotherapy. 2016;36:342-347.

9. Kiel PJ, McCord AD. Pharmacist impact on clinical outcomes in a diabetes disease management program via collaborative practice. Ann Pharmacother. 2005;39:1828-1832.

10. Farland MZ, Byrd DC, McFarland MS, et al. Pharmacist-physician collaboration for diabetes care: the diabetes initiative program. Ann Pharmacother. 2013;47:781-789.

11. Howard-Thompson A, Farland MZ, Byrd DC, et al. Pharmacist-physician collaboration for diabetes care: cardiovascular outcomes. Ann Pharmacother. 2013;47:1471-1477.

12. Gums TH, Carter BL, Milavetz G, et al. Physician-pharmacist collaborative management of asthma in primary care. Pharmacotherapy. 2014;34:1033-1042.

13. Greer N, Bolduc J, Geurkink E, et al. VA Evidence-based Synthesis Program Reports. Pharmacist-Led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared to Usual Care. Washington (DC): Department of Veterans Affairs (US); 2015.

14. Wentzlaff DM, Carter BL, Ardery G, et al. Sustained blood pressure control following discontinuation of a pharmacist intervention. J Clin Hypertens (Greenwich). 2011;13:431-437.

15. Carter BL, Vander Weg MW, Parker CP, et al. Sustained blood pressure control following discontinuation of a pharmacist intervention for veterans. J Clin Hypertens (Greenwich). 2015;17:701-708.

16. Kulchaitanaroaj P, Brooks JM, Ardery G, et al. Incremental costs associated with physician and pharmacist collaboration to improve blood pressure control. Pharmacotherapy. 2012;32:772-780.

17. Polgreen LA, Han J, Carter BL, et al. Cost effectiveness of a physician-pharmacist collaboration intervention to improve blood pressure control. Hypertension. 2015;66:1145-1151.

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19. Anderegg MD, Gums TH, Uribe L, et al. Physician-pharmacist collaborative management: narrowing the socioeconomic blood pressure gap. Hypertension. 2016;68:1314-1320.

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Overcoming implementation challenges

Implementation of pharmacist collaboration within primary care medicine may pose a challenge, as the requirements and resources vary widely among primary care settings. Health-system administrators, for example, may need to reorganize the clinic structure and budget resources in order to overcome some of the obstacles to implementing a PPCM model.

Researchers found that patients in a physician-pharmacist collaborative management model had significantly greater reductions in BP than those in the control group.

Experts have reported several strategies that help in establishing PPCM within primary care clinics,¹⁸ including proactively identifying patients who may benefit from pharmacist intervention, requiring appropriate training and credentialing of pharmacists, and establishing a set schedule for pharmacists to interview patients. Clinics would also be well served to model interventions outlined in the studies mentioned in this article and provide adequate time for pharmacists to perform structured activities, including review of medication history, assessment of current disease state control, and adjustment of medication therapy regimens. And, of course, given the diversity of primary care settings, administrators will need to identify the specific PPCM strategies that best complement their respective collaborative practice plans and environments.

The lack of well-defined reimbursement models for pharmacy services has presented a challenge for generating revenue and effectively implementing PPCM within many primary care settings. Currently, the Centers for Medicare and Medicaid Services and third-party payers do not recognize pharmacists as independent providers, creating a barrier for obtaining reimbursement for clinical pharmacy services. Typically, pharmacists have charged for clinic visits under a consultant physician through the “incident to” billing model, with the option to bill at higher levels if the patient was seen jointly with the physician.

Can this model benefit the underserved?

A prospective, cluster-randomized clinic study has shown pharmacist intervention to reduce racial and socioeconomic disparities in the treatment of elevated BP.¹⁹This study is the first to show that a team-care model can overcome inequalities arising from low income, low patient education status, and little or no insurance to produce the same health care benefit as in those with higher socioeconomic and educational status. This type of collaborative care model may be particularly beneficial when incorporated within a PCMH catering to underserved populations.²⁰

Implementation of a physician-pharmacist collaborative management model reduced the average HbA1c by 1.2%.

However, sparse data currently exist regarding the benefits of the PPCM model within a PCMH, despite the fact that integration of this type of collaborative model is expected to contribute positively to patient care.²¹

Physician acceptance of pharmacist involvement is mixed

While physician acceptance of pharmacist recommendations is generally high, at least one study indicated that some health-care professionals in patient-care teams are reluctant to incorporate pharmacists into a PCMH. Reasons include difficulty in coordination of care with pharmacy services and limited knowledge by other professionals of pharmacists’ training.²²

Centralization can combat a lack of resources

As noted earlier, primary care offices that implement PPCM models are mostly academically affiliated or are part of large health systems. Many private primary care offices lack the resources to employ a pharmacist in their office. As an alternative, prospective clinical trials are looking at a centralized, Web-based cardiovascular risk service managed by pharmacists.^23,24 This service’s primary objective is to improve adherence to metric-based outcomes developed as part of The Guideline Advantage quality improvement program put forth by the American Cancer Society, American Diabetes Association, and the American Heart and Stroke Associations. (See http://www.guidelineadvantage.org/TGA/ for more information.)

Researchers hope to prove that a centralized, pharmacist-run, clinical service can meet metric-driven outcomes that many primary care offices are now being required to meet in order to receive compensation from insurance companies. One of these studies is specifically looking at rural private offices that lack many of the resources that many large academic offices possess.²³The study is ongoing and results are expected sometime in 2018.

CORRESPONDENCE
John G. Gums, PharmD, College of Pharmacy, University of Florida, 1225 Center Drive, HPNP 4332, Gainesville, FL 32601; jgums@ufl.edu.