Do you go to the same pharmacy all the time to have your prescriptions filled? Many people shop around for the best price so don't end up at the same place all the time, while others order medicines online, with attendant risks of that practice. But now that pharmacists are being called upon to do more and more when it comes to helping people manage their own health, perhaps you'd like to select a 'pharmacy home,' and stick with it, especially in light of a study on home blood pressure monitoring and medication management in JAMA Rick and I discuss on PodMed this week.
People with high blood pressure who weren't meeting their goals with regard to blood pressure lowering were recruited to this study of telemonitoring of blood pressure at home with medication adjustment in consultation with a pharmacist versus usual care. A total of 450 patients were enrolled, with 222 receiving usual care and 228 in the intervention arm. Those who were randomized to the intervention arm received a home blood pressure monitor capable of transmitting their readings to a pharmacist. After a 1 hour session with the pharmacist they were asked to record blood pressures 6 times each day, 3 in the morning and 3 in the evening. During the first six months of the study subjects met with the pharmacist once every two weeks by telephone until blood pressure was controlled and sustained for 6 weeks, then phone calls took place once per month for months 7-12 of the study.
The pharmacist's role in the this study was substantial. Each time they interacted with a subject they discussed the importance of medication adherence as important in achieving blood pressure control, along with lifestyle changes. They adjusted the subject's medications using an algorithm based on the percentage of home blood pressure values meeting goal, and they could also switch medications or lower dosages if adverse effects were seen. All information was communicated with the patient's primary care providers. Those study subjects randomized to usual care saw their primary care providers as usual.
The study's primary outcome measure was the proportion of subjects whose blood pressure was under control at six and twelve months of the study. Other measures included diastolic and systolic blood pressure control considered separately, and blood pressure control at 18 months. Patient satisfaction was also assessed. Researchers found that 57.2% of the people in the intervention group achieved goal at 6 and 12 months, in comparison to 30% of those in the usual care group. At 18 months 71.8% of those in the intervention group were at goal, versus 57.1% of those in the usual care group. Similar rates of satisfaction were reported in both groups.
Now here's the rub: what about costs? The authors estimate that such a program would cost about $1350.00 per person for a 12 month intervention. Who's paying? Isn't that a good question? At the moment there's no mechanism for paying for this intervention, either for the provision of a blood pressure monitor or for pharmacist time, yet expectations with regard to pharmacist involvement continue to escalate. If I were a pharmacist I might be a bit miffed. For now at least one aspect of the study seems practical: getting people involved in their own blood pressure monitoring. As for the rest, guess we'll see what healthcare reform provides.
Other topics this week include rates of mental disorders in offspring conceived with IVF, also in JAMA, a new medication for diabetes in Annals of Internal Medicine, and in JAMA Internal Medicine overuse of cholesterol testing. Until next week, y'all live well.