Health care providers face many challenges in utilizing cardiovascular therapies, such as anticipated shortages in physicians, patients with more complicated conditions, shifting medication regimens, management needs, and increased accountability for quality and performance measures.1 To meet the potential increase in service demand, cardiology practices are embracing cardiovascular team-based care.1 Advanced practice providers, such as advanced practice registered nurses (APRNs), physician assistants (PAs), and clinical pharmacy specialists (CPSs), have education, training, and experience to extend the team’s capability to meet these complex management needs.1
The role of CPSs within a cardiovascular care team includes providing a variety of patient-specific services, such as collaborating with other cardiology providers, to optimize evidence-based pharmacotherapy, preventing medication-related adverse events/errors, improving patient understanding of their medication regimen, and ultimately, improving patient outcomes.2 Health care systems, such as Kaiser Permanente of Colorado, have demonstrated improved clinical outcomes for patients with coronary artery disease (CAD) by implementing a multidisciplinary collaborative cardiac care service, including a clinical pharmacy cardiac risk service, in which CPSs assisted with management of cholesterol-lowering, hypertension, diabetes mellitus (DM), and smoking-cessation therapies, which resulted in a 76% to 89% reduction in all-cause mortality associated with CAD in multiple evaluations.3,4
Pharmacists providing medication therapy management (MTM) services in Minnesota had higher goal attainment for patients with hypertension and hyperlipidemia than did pharmacists who did not provide MTM services.5 MTM services provided by pharmacists led to an improvement in clinical outcomes for patients as well as a reduction in overall health care expenditures compared with that of a control group of patients who did not receive MTM services.5 Furthermore, CPS integration in the heart failure (HF) setting has led to improvements in utilization and optimization of guideline-directed medical therapies, an area in which recent data have suggested deficiencies exist.6-8 A full review of the outcomes associated with CPS involvement in cardiovascular care is beyond the scope of this article; but the recent review by Dunn and colleagues provides more detail.2
With the increasing number of patients with cardiovascular disease,expanding integration of CPSs in the cardiovascular team providing MTM services may reduce the burden of other providers (MD, PA, APRN, etc), thereby increasing access for not only new patients, but also diagnostic and interventional work, while potentially improving clinical and economic outcomes.2 The value of integrating CPSs as members of the cardiovascular care team is recognized in a variety of inpatient and ambulatory practice settings.2-6 However, data are limited on the number and types of interventions made per encounter as direct patient care providers. Expanded granularity regarding the effect of CPSs as active members of the cardiovascular team is an essential component to evaluate the potential benefit of CPS integration into direct patient care.
Methods
The West Palm Beach (WPB) Veteran Affairs Medical Center (VAMC) outpatient cardiology clinic consists of 6 full-time employee (FTE) cardiologists, 4 PAs or APRNs, 10 other cardiology health care staff members (registered/license practical nurses and technicians), and 2 cardiology CPSs providing direct patient care and, cumulatively, 1 clinic-assigned clinical pharmacy FTE. The cardiology CPSs provide comprehensive MTM based on patient-specific needs in an ambulatory cardiology pharmacotherapy clinic.