When it comes to cardiac disease, pharmacists in all practice settings can make a difference.
Pharmacists have a role in the chronic disease state management of patients with cardiac disease.
Since the push from Medicare and Medicaid, as well as from private payers, to manage complex disease states, health-care teams are managing these diseases, in large part through ambulatory clinics. The role of the pharmacist in this type of environment, says Norman P. Tomaka, BS Pharm, MS, a Media Liaison to APhA is to “ensure patients are compliant with their cardiac medications to help prevent readmissions and other untoward outcomes.” But pharmacists in other settings have a role to play, too. In many hospitals, for example, pharmacists meet directly with patients to discuss medication regimens.
The value of the pharmacist as a member of the cardiac health-care team has been clearly documented. The 2017 Hypertension Clinical Practice Guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC) recommend a team-based approach, which includes pharmacists, in the treatment of hypertension. “There is high-quality evidence demonstrating that team-based models, particularly with pharmacists and nurses, improve hypertension treatment and control, says Eric McLaughlin, PharmD, BCPS, FASHP, FCCP, who coauthored the guidelines as APhA’s representative. “With the formal recommendation to use a team-based approach for the care of hypertension patients, there would be an expanded role and opportunities [for pharmacists],” says MacLaughlin in a written release.
A study conducted in the cardiology unit of a university-affiliated hospital demonstrated that correction of drug-related problems (DRPs) by physicians after a pharmacist’s advice caused a significant decrease in mortality as analyzed by propensity-score (PS) matching. A total of 1,541 interventions were suggested by the clinical pharmacist in the study group; 1,416 (92%) of them were accepted by the cardiology team. All-cause mortality was reduced from 1.7% during Phase I (preintervention) to 1.0% during Phase II (postintervention). The difference was statistically significant (P=0.0074).1
The pharmacist is valued as a member of the health-care team in treating patients with cardiac disease,” says Brittany Todd, PharmD, BCBS, CLS, Clinical Pharmacy Specialist in the Clinical Pharmacy Cardiac Risk Service (CPCRS), at Kaiser Permanente Colorado (KPCO) in an interview with Drug Topics.
At the facility, a team of clinical pharmacists and clinical pharmacy specialists manage most patients with atherosclerotic disease (ASCVD). “At KPCO, our providers know of the Clinical Pharmacy Cardiac Risk Service and rely on us for long-term management of their patients with ASCVD,” says Todd. “As pharmacists, we work closely with our primary care providers, cardiologists, neurologists, and cardiac rehab nurses to ensure all parties are on the same page with patient care.” [see Table 1]
“Within CPCRS, we are able to manage multiple disease states,” Todd continues. “Pharmacists ensure appropriate management of dyslipidemia, hypertension, diabetes, and smoking cessation. We order labs and instruct patients to follow up in clinics regarding blood pressure or any uncontrolled issue,” she says.
“We work off a Collaborative Drug Therapy Management document that outlines what we can and cannot do,” Todd says. The physician representatives for KPCO review this document annually to ensure that pharmacists manage their patients appropriately based on guidelines, evidence-based medicine, and safe practices. Because of the protocol, “we make therapy changes. We simply notify the physician of any therapy changes we made,” she says.
“I feel our providers understand what a pharmacist brings to the table-medication expertise-and truly appreciate our role,” Todd says.
A collaboration between a pharmacy and a hospital in Virginia is serving the needs of cardiac patients as they transition from hospital to discharge. Bremo Pharmacy, which also has a long-term care and community pharmacy in its group, is situated right in Henrico Doctors’ Hospital in Richmond, VA.
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Pharmacists spend time at each patient’s bedside prior to discharge to ensure that the patient understands their medication regimen. Mary Curtis, PharmD, is assigned to the cardiac unit. “We educate the patient on their medications and potential side effects,” she says. Our goal is to send the patient home on appropriate therapy and lower our readmission rates.”
Pharmacists also “meet” with patients via FaceTime at Parham Doctors’ Hospital, also in Richmond.
The program is expanding to include a pharmacist’s intervention up to the patient’s first postdischarge physician visit. The pilot program, which is focusing on high-risk patients, started in January. The emphasis, says Curtis, is on chronic care management. “By the time the patient goes back to the doctor, we will have provided the physician with a postdischarge medication reconciliation, and other pertinent information,” Curtis says. This gives the cardiologist a heads-up on what to expect before the patient arrives for their appointment.
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After that first physician visit, the patient is welcome to continue having their prescriptions filled at Bremo, if they choose Curtis says.
Curtis explains that the Bremo pharmacists do not work within a collaborative drug therapy agreement, but feels that pharmacists and physicians have a strong relationship. “The physician can open the door to help the patient accept the pharmacist as a member of the health-care team,” she says.
Community pharmacists are making a difference as well, says Tomaka. Many community pharmacists provide blood pressure screenings, as well as counsel patients on lifestyle issues, such as diet and exercise. Others have smoking cessation programs.
Tomaka cites an example from his own experience as a community pharmacist when he encouraged a patient to have a blood pressure reading in the pharmacy. It was determined that the patient was having an adverse reaction to a new medication, and the proper adjustment was made. In another instance, a patient was encouraged to take a blood pressure medication at a different time of day to avoid a side effect that was affecting quality of life.
The community pharmacist is in a good position to counsel patients on lifestyle issues, Tomaka says. A good resource for the pharmacist is the American Heart Association’s Diet and Lifestyle Recommendations.
At Kaiser, Todd agrees that lifestyle issues are important. “We do focus quite a bit on therapies since we are pharmacists, but with each call (or at least we try), we talk about lifestyle. This includes a heart-healthy diet, weight loss, and exercise,” she says. “A unique part of what we do is allow time with patients to really get into the why. Many patients with ASCVD are told to take meds, lose weight, etc. This is overwhelming and they are never taught why it is so important. We are able to develop relationships with these patients since we follow them long-term,” she says.
Curtis agrees. “It’s important for a patient to understand their meds, as well as to understand why lifestyle issues, such as diet and exercise are important. As a pharmacist, to give guidance to a patient, and to come to the point where you see that patient feeling better, is very rewarding.”
1. Zhai X, Gu Z, Liu X. Effectiveness of the clinical pharmacist in reducing mortality in hospitalized cardiac patients: a propensity score-matched analysis. Ther Clin Risk Manag. 2016;12:241-250.