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An Unmet Need Meets an Untapped Resource: Pharmacist-Led Pathways for Hypertension Management for Emergency Department Patients

  • Hypertension and Emergency Medicine (T Rainer and P Levy, Section Editors)
  • Published:
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Abstract

Purpose of Review

The purpose of this review is to describe the role of the pharmacist in innovative pathways of care for hypertension (HTN) management for emergency department (ED) patients, particularly in under-resourced communities. Due to intersecting socioeconomic and personal health risk factors, these patients bear a disproportionate share of cardiovascular disease, yet often have limited access to high-quality primary care.

Recent Findings

Recent meta-analyses demonstrate a clear advantage associated with pharmacist-physician collaborative models over traditional physician-only care in achieving blood pressure control. However, no prior study has evaluated use of pharmacist-led follow-up for ED patients with uncontrolled blood pressure (BP). Thus, we developed a pharmacist-driven transitional care clinic (TCC) that utilizes a collaborative practice agreement with ED physicians to improve HTN management for ED patients. We have successfully implemented the TCC in a high-volume urban ED and in a pilot study have shown clinically relevant BP reductions with our collaborative model.

Summary

The use of pharmacist-led follow-up for HTN management is highly effective. Novel programs such as our TCC, which extend the reach of such a model to ED patients, are promising, and future studies should focus on implementation through larger, multicenter, randomized trials. However, to be most effective, policy advocacy is needed to expand pharmacist prescriptive authority and develop innovative financial models to incentivize this practice.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Fryar CD. Hypertension prevalence and control among adults: United States, 2015–2016. NCHS data brief. 2017;(289):1–8.

  2. Benjamin Emelia J, Virani Salim S, Callaway Clifton W, Chamberlain Alanna M, Chang Alexander R, Cheng S, et al. Heart Disease and Stroke Statistics—2018 Update: a report from the American Heart Association. Circulation. 2018;137(12):e67–e492. https://doi.org/10.1161/CIR.0000000000000558.

    Article  CAS  PubMed  Google Scholar 

  3. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;2017:e127–248. https://doi.org/10.1016/j.jacc.2017.11.006.

    Article  Google Scholar 

  4. Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103–16. https://doi.org/10.1056/NEJMoa1511939.

    Article  CAS  PubMed  Google Scholar 

  5. Muntner P, Carey RM, Gidding S, Jones DW, Taler SJ, Wright JT, et al. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. Circulation. 2018;137(2):109–18. https://doi.org/10.1161/CIRCULATIONAHA.117.032582.

    Article  PubMed  Google Scholar 

  6. Mills KT, Obst KM, Shen W, Molina S, Zhang HJ, He H, et al. Comparative effectiveness of implementation strategies for blood pressure control in hypertensive patients: a systematic review and meta-analysis. Ann Intern Med. 2018;168(2):110–20. https://doi.org/10.7326/M17-1805.

    Article  PubMed  Google Scholar 

  7. Levy PD, Cline D. Asymptomatic hypertension in the emergency department: a matter of critical public health importance. Acad Emerg Med. 2009;16(11):1251–7. https://doi.org/10.1111/j.1553-2712.2009.00512.x.

    Article  PubMed  Google Scholar 

  8. McNaughton CD, Self WH, Zhu Y, Janke AT, Storrow AB, Levy P. Incidence of hypertension-related emergency department visits in the United States, 2006 to 2012. Am J Cardiol. 2015;116(11):1717–23. https://doi.org/10.1016/j.amjcard.2015.09.007.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Niska RW. Blood pressure measurements at emergency department visits by adults: United States. NCHS Data Brief. 2007-2008;2011(72):1–8.

    Google Scholar 

  10. Adhikari S, Mathiasen R. Epidemiology of elevated blood pressure in the ED. Am J Emerg Med. 2014;32(11):1370–2. https://doi.org/10.1016/j.ajem.2014.08.034.

    Article  PubMed  Google Scholar 

  11. Cheung PT, Wiler JL, Lowe RA, Ginde AA. National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries. Ann Emerg Med. 2012;60(1):4–10.e2. https://doi.org/10.1016/j.annemergmed.2012.01.035.

    Article  PubMed  Google Scholar 

  12. Capp R, Kelley L, Ellis P, Carmona J, Lofton A, Cobbs-Lomax D, et al. Reasons for frequent emergency department use by Medicaid enrollees: a qualitative study. Acad Emerg Med. 2016;23(4):476–81. https://doi.org/10.1111/acem.12952.

    Article  PubMed  Google Scholar 

  13. Decker WW, Godwin SA, Hess EP, Lenamond CC, Jagoda AS. Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department. Ann Emerg Med. 2006;47(3):237–49. https://doi.org/10.1016/j.annemergmed.2005.10.003.

    Article  PubMed  Google Scholar 

  14. Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM. Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013;62(1):59–68. https://doi.org/10.1016/j.annemergmed.2013.05.012.

    Article  PubMed  Google Scholar 

  15. Lehrmann JF, Tanabe P, Baumann BM, Jones MK, Martinovich Z, Adams JG. Knowledge translation of the American College of Emergency Physicians clinical policy on hypertension. Acad Emerg Med. 2007;14(11):1090–6. https://doi.org/10.1197/j.aem.2007.05.016.

    Article  PubMed  Google Scholar 

  16. Baumann BM, Cline DM, Cienki JJ, Egging D, Lehrmann JF, Tanabe P. Provider self-report and practice: reassessment and referral of emergency department patients with elevated blood pressure. Am J Hypertens. 2009;22(6):604–10. https://doi.org/10.1038/ajh.2009.44.

    Article  PubMed  Google Scholar 

  17. Adhikari S, Mathiasen R, Lander L. Elevated blood pressure in the emergency department: lack of adherence to clinical practice guidelines. Blood Press Monit. 2016;21(1):54–8. https://doi.org/10.1097/MBP.0000000000000158.

    Article  PubMed  Google Scholar 

  18. Baumann BM, Abate NL, Cowan RM, Chansky ME, Rosa K, Boudreaux ED. Characteristics and referral of emergency department patients with elevated blood pressure. Acad Emerg Med. 2007;14(9):779–84. https://doi.org/10.1197/j.aem.2007.05.008.

    Article  PubMed  Google Scholar 

  19. Brody A, Rahman T, Reed B, Millis S, Ference B, Flack JM, et al. Safety and efficacy of antihypertensive prescription at emergency department discharge. Acad Emerg Med. 2015;22(5):632–5. https://doi.org/10.1111/acem.12660.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Brody AM, Sharma VK, Singh A, Kumar VA, Goldberg EM, Millis SR, et al. Barriers to emergency physician diagnosis and treatment of uncontrolled chronic hypertension. Am J Emerg Med. 2016;34(11):2241–2. https://doi.org/10.1016/j.ajem.2016.08.050.

    Article  PubMed  Google Scholar 

  21. Souffront K, Chyun D, Kovner C. Barriers to referral for elevated blood pressure in the emergency department and differences between provider type. J Clin Hypertens (Greenwich). 2015;17(3):207–14. https://doi.org/10.1111/jch.12468.

    Article  Google Scholar 

  22. • Levy PD. Whose job is it anyway? Academic Emergency Medicine. 2019. doi:https://doi.org/10.1111/acem.13762. A commentary on ED physicians to look for possible alternatives to managing patient health.

    Article  Google Scholar 

  23. Naderi S, Barnett B, Hoffman RS, Dalipi R, Houdek L, Alagappan K, et al. Factors associated with failure to follow-up at a medical clinic after an ED visit. Am J Emerg Med. 2012;30(2):347–51. https://doi.org/10.1016/j.ajem.2010.11.034.

    Article  PubMed  Google Scholar 

  24. Gordon C, Unni E, Montuoro J, Ogborn DB. Community pharmacist-led clinical services: physician’s understanding, perceptions and readiness to collaborate in a Midwestern state in the United States. Int J Pharm Pract. 2018;26(5):407–13. https://doi.org/10.1111/ijpp.12421.

    Article  PubMed  Google Scholar 

  25. Advancing team-based care through collaborative practice agreements: a resource and implementation guide for adding pharmacists to the care team. . Atlanta, GA: Centers for Disease Control and Prevention: Department of Health and Human Services2017.

  26. Weaver KK. Collaborative practice agreements: explaining the basics. Pharmacy Today. 2018; 24(3):55

    Article  Google Scholar 

  27. Community Preventive Services Task F. Team-based care to improve blood pressure control: recommendation of the community preventive services task force. Am J Prev Med. 2014;47(1):100–2. https://doi.org/10.1016/j.amepre.2014.03.003.

    Article  Google Scholar 

  28. Isetts BJ, Buffington DE, Carter BL, Smith M, Polgreen LA, James PA. Evaluation of Pharmacists' work in a physician-pharmacist collaborative model for the management of hypertension. Pharmacotherapy. 2016;36(4):374–84. https://doi.org/10.1002/phar.1727.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Kennelty KA, Polgreen LA, Carter BL. Team-based care with pharmacists to improve blood pressure: a review of recent literature. Curr Hypertens Rep. 2018;20(1):1. https://doi.org/10.1007/s11906-018-0803-0.

    Article  PubMed  PubMed Central  Google Scholar 

  30. • Santschi V, Chiolero A, Colosimo AL, Platt RW, Taffé P, Burnier M, et al. Improving blood pressure control through pharmacist interventions: a meta-analysis of randomized controlled trials. Journal of the American Heart Association. 2014;3(2):e000718-e. https://doi.org/10.1161/JAHA.113.000718 A meta-analysis on improving BP control via pharmacist interventions.

    Article  Google Scholar 

  31. Lackland DT. Racial differences in hypertension: implications for high blood pressure management. Am J Med Sci. 2014;348(2):135–8. https://doi.org/10.1097/MAJ.0000000000000308.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Wenger LM, Rosenthal M, Sharpe JP, Waite N. Confronting inequities: a scoping review of the literature on pharmacist practice and health-related disparities. Res Social Adm Pharm. 2015;12:175–217. https://doi.org/10.1016/j.sapharm.2015.05.011.

    Article  PubMed  Google Scholar 

  33. •• Carter Barry L, Coffey Christopher S, Ardery G, Uribe L, Ecklund D, James P, et al. Cluster-Randomized Trial of a physician/pharmacist collaborative model to improve blood pressure control. Circ Cardiovasc Qual Outcomes. 2015;8(3):235–43. https://doi.org/10.1161/CIRCOUTCOMES.114.001283 A large RCT focusing on pharmacist-led management in 32 physician offices.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Sisson EM, Dixon DL, Kildow DC, Van Tassell BW, Carl DE, Varghese D, 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(3):342–7. https://doi.org/10.1002/phar.1710.

    Article  PubMed  Google Scholar 

  35. Roman C, Edwards G, Dooley M, Mitra B. Roles of the emergency medicine pharmacist: a systematic review. Am J Health Syst Pharm. 2018;75(11):796–806. https://doi.org/10.2146/ajhp170321.

    Article  PubMed  Google Scholar 

  36. Vrijens B, Antoniou S, Burnier M, de la Sierra A, Volpe M. Current situation of medication adherence in hypertension. Front Pharmacol. 2017;8:100.

    Article  Google Scholar 

  37. Vrijens B, De Geest S, Hughes DA, Przemyslaw K, Demonceau J, Ruppar T, et al. A new taxonomy for describing and defining adherence to medications. Br J Clin Pharmacol. 2012;73(5):691–705. https://doi.org/10.1111/j.1365-2125.2012.04167.x.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol A randomized controlled trial. JAMA. 2006;296(21):2563–71. https://doi.org/10.1001/jama.296.21.joc60162.

    Article  CAS  PubMed  Google Scholar 

  39. • Kuhmmer R, Lima KM, Ribeiro RA, Hammes LS, Bastos GAN, Cotta de Souza MCS, et al. Effectiveness of pharmaceutical care at discharge in the emergency department: study protocol of a randomized controlled trial. Trials. 2015;16(1):60. https://doi.org/10.1186/s13063-015-0579-3 A procedural model analysis of pharmaceutical care effectiveness.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Hohner E, Ortmann M, Murtaza U, Chopra S, Ross PA, Swarthout M, et al. Implementation of an emergency department–based clinical pharmacist transitions-of-care program. Am J Health Syst Pharm. 2016;73(15):1180–7. https://doi.org/10.2146/ajhp150511.

    Article  PubMed  Google Scholar 

  41. Atzema CL, Maclagan LC. The transition of care between emergency department and primary care: a scoping study. Acad Emerg Med. 2017;24(2):201–15. https://doi.org/10.1111/acem.13125.

    Article  PubMed  Google Scholar 

  42. Chou S-C, Deng Y, Smart J, Parwani V, Bernstein SL, Venkatesh AK. Insurance status and access to urgent primary care follow-up after an emergency department visit in 2016. Ann Emerg Med. 2018;71(4):487–96.e1. https://doi.org/10.1016/j.annemergmed.2017.08.045.

    Article  PubMed  Google Scholar 

  43. •• Brody A, Stewart B, Zhang L, Levy P. Can pharmacists effectively manage blood pressure for discharged urban emergency department patients with uncontrolled hypertension? ACEP: Annals of Emergency Medicine. 2018;72(4):S36–S7.An abstract submission on summary evidence of pharmacist impact on ED patients.

    Article  Google Scholar 

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Acknowledgments

The authors would like to acknowledge the Eugene Applebaum College of Pharmacy and Health Sciences and the National Association of Chain Drug Stores for providing funding support for the transitional care clinic research.

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Authors and Affiliations

  1. Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave., Detroit, MI, 48201, USA

    Brittany Stewart

  2. Department of Emergency Medicine and Integrative Biosciences Center, Wayne State University, 6135 Woodward Ave., Detroit, MI, 48202, USA

    Aaron Brody & Phillip D. Levy

  3. Department of Physiology and Integrative Biosciences Center, Wayne State University, 6135 Woodward Ave., Detroit, MI, 48202, USA

    Abhinav C. Krishnan

  4. Meijer Pharmacy/Wayne State University Community-based Pharmacy Practice Resident, 13000 Middlebelt Rd., Livonia, MI, 48150, USA

    Sara K. Brown

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Correspondence to Brittany Stewart.

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Stewart, B., Brody, A., Krishnan, A.C. et al. An Unmet Need Meets an Untapped Resource: Pharmacist-Led Pathways for Hypertension Management for Emergency Department Patients. Curr Hypertens Rep 21, 61 (2019). https://doi.org/10.1007/s11906-019-0965-4

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