You Don’t Know What You’ve Got Till It’s Gone

John G. Gums, Pharm.D., FCCP

Key Words: ambulatory care, hypertension, pharmacist intervention,physician-pharmacist collaboration, primary care.(Pharmacotherapy 2010;30(3):221–223)

In this issue of Pharmacotherapy, Dr. BarryCarter and his colleagues discuss the impact onblood pressure control after discontinuation of aphysician-pharmacist collaborative intervention.1

Previously, these authors demonstrated that in a9-month intervention study, physician-pharmacistcollaboration resulted in a significantly higherpercentage of patients who achieved bloodpressure control compared with a control group.2

In the current study,1 the authors extended theirevaluation of the previous intervention study2 byevaluating blood pressure control at 9 and 18months after they removed the physician-pharmacist collaborative intervention—a “de-intervention” study. At 9 months, systolic bloodpressure rose from a mean ± SD nadir of 124.5 ±10.7 mm Hg in the original intervention group to131.0 ± 12.2 mm Hg. In addition, the percentageof patients with controlled blood pressuredropped from 78.5% after the intervention to53.9%. In the original control group, systolicblood pressure rose from a mean ± SD nadir of132.0 ± 15.1 mm Hg to 143.3 ± 17.5 mm Hg at 9months after discontinuation of the collaborativeintervention. The percentage of patients withcontrolled blood pressure dropped from 48.7% to30.8% in this group. The authors concluded thateven though there was some evidence of a

sustained effect on blood pressure control afterdiscontinuation of the physician-pharmacistcollaborative intervention, continued interventionby the pharmacist may be necessary to maintainhigh rates of blood pressure control.

At times, it seems like we have a long way togo to convince insurance companies and payersof the value of clinical pharmacist intervention.Some of this, I believe, is due to the fact thatpharmacists have spent most of their timedocumenting their impact in a cost savingsmodel. Since a dollar saved is less valuable thana dollar earned, the pharmacy community stillhas work to do to achieve independent providerstatus that health care payers will recognize.Outside the reimbursement discussion, however,there is little doubt that pharmacy interventionleading to improved outcomes and reducedhealth care costs is an evidenced-based conclusion.

Thirty-seven years ago, the positive impact thata pharmacist could have on patients’ hypertensionmanagement and adverse effects was demonstratedin a landmark trial of 50 patients from the ModelNeighborhood Comprehensive Health Programin Detroit, Michigan.3 This is even more impressivetoday when you realize that almost 30% of thestudy patients were taking methyldopa andanother 12% were taking guanethidine. Since1973 (when this study was published), themedical and pharmacy literature is replete withstudies, reports, and editorials documenting andprofessing the positive impact and value ofadding a clinical pharmacist to a team model in avariety of disease entities. But rarely, however, dowe see the evaluation of what happens after weremove the intervention.

One of the few such reports documented theimpact of a clinical pharmacist on drug therapyadherence, systolic blood pressure, and low-density lipoprotein cholesterol concentrations

From the Department of Pharmacotherapy andTranslational Research and the Department of CommunityHealth and Family Medicine, University of Florida,Gainesville, Florida.

The opinions expressed in this editorial are those of theauthor and do not necessarily represent the position ofPharmacotherapy or the American College of ClinicalPharmacy. Invited editorials are not peer reviewed.

For reprints, visit http://www.atypon-link.com/PPI/loi/phco.For questions or comments, contact John G. Gums, Pharm.D.,FCCP, Department of Pharmacotherapy and TranslationalResearch and Department of Community Health and FamilyMedicine, University of Florida, 625 Southwest FourthAvenue, Gainesville, FL 32601; e-mail: jgums@ufl.edu.

PHARMACOTHERAPY Volume 30, Number 3, 2010

after a 6-month intervention phase and thenagain at 6 months after removing the inter-vention.4 Although there were minimal changesto the blood pressure and cholesterol levelvariables after removal of the pharmacy inter-vention, drug adherence, which had increasedfrom a baseline of 61.2% to 96.9% after the 6-month intervention, subsequently dropped to69.1% after removal of the pharmacist interven-tion. Unfortunately, these type of studies are fewand far between.

Historically, it has been assumed that provingthat a clinical pharmacy intervention wasclinically beneficial and economically valuablewould be enough to move the profession towardthe status of an independent reimbursableprovider. In retrospect, that was probably notsmart. That approach does address the payer’squestion of why they should pay for sustainedintervention in a chronic disease managementprogram. If you think about it, rarely do weaccept that level of proof for other suspectedrelationships in medicine. In a situation wherethere is a suspected drug-induced adverse effector drug-drug interaction, we often will not assignvalidity or causality to the relationship unlessrechallenge confirms it.

There certainly is and was considerable valueassociated with the traditional studies docu-menting that adding a pharmacist intervention,collaborative or not, makes a clinical andeconomic difference. The profession needed toprove their worth. But after 30 years of provingthat adding a pharmacist to the treatmentequation is valuable, we still are sitting on theoutside of the provider reimbursement discus-sion. What I am left wondering is whether weshould have been extending our methodology toinvestigate the impact of what happens after weremove the pharmacist—what I would call the“now you see it, now you don’t” methodology.

In our personal lives, how often do we findourselves complaining about something (orsomeone) when they are present, only to findhow much we missed it (or them) as soon as theywere gone? We have a tendency to take forgranted what we have and to not fully appreciateit until we no longer have it. To an extent, Ithink that has happened with clinical pharmacists.

Therein lies the importance of the “de-intervention” trial in this issue of the journal.1 Itbecomes vitally important as we push forindependent practitioner status in the world ofreimbursement to prove not only that we make adifference but that our sustained involvement is

necessary to continue to reap the medical andeconomic benefits of disease state management.Without that critical component, payers couldargue that a one-time pharmacy consultation isall that is necessary. How easy would it havebeen for those of us who conducted thoseintervention trials to just collect a little more dataafter the intervention was discontinued? Weneed to strongly consider adding this componentto future research endeavors to document thevalue of maintaining pharmacist intervention.

In their study, Dr. Carter and his colleaguessuggest that removal of any “Hawthorne” effectafter the 9-month intervention could have led toblood pressure control deterioration.1 They alsosuggest that deterioration could have occurreddue to the need for greater numbers of antihyper-tensive drugs with long-term follow-up. Theauthors recommend that whatever the reason, a“booster” intervention may be required and thatpharmacists should reengage in any patient inwhom blood pressure becomes uncontrolled.The authors point out the obvious limitations ofthe study such as the small sample size, changein blood pressure measurement method betweenthe intervention and postintervention evaluations,and the fact that the study did not account forother prescription or nonprescription drugs thatmight have changed over time.

Whereas any of the above caveats alone or incombination could have affected the results, itdoes not detract from the importance of thestudy. The National Interdisciplinary PrimaryCare Practice-based Research Network, a multi-site primary care research network registeredwith the Agency for Healthcare Research andQuality, is currently conducting the CollaborationAmong Pharmacists and Physicians to ImproveOutcomes Now (CAPTION) trial, funded by agrant from the National Institutes of Health.5

This trial has as one of its objectives to prospec-tively study the discontinuation of physician-pharmacist collaborative management in a large,multicenter hypertensive population. Thefunding of this type of study underscores theimportance that is being placed on large-scale,across-the-board implementation of pharmacistintervention and the health care value associatedwith maintaining that intervention.

The timing for this discussion could not bebetter. In the current climate of health carereform and the medical home model, we need tofind better and more efficient ways to care forpatients with chronic diseases. Maybe even moreimportant, we need to raise the value assigned to

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VALUE OF SUSTAINED PHYSICIAN-PHARMACIST COLLABORATIVE INTERVENTION Gums

preventing or at least delaying the onset ofchronic disease. Dr. Carter and his colleagues areto be congratulated for adjusting the barometerthat judges the total value of pharmacistintervention. Indeed, more studies are neededthat document the health and economic value ofsustained pharmacist intervention.

Because at the end of the day, it is the sustain-ability and persistence of the benefits that phar-macists uniquely bring to the table that willdetermine whether we receive recognition andreimbursement as independent practitioners,untethered by any collaborative bond withphysicians.

References1. Carter BL, Doucette WR, Franciscus CL, Ardery G, Kluesner

KM, Chrischilles EA. Deterioration in blood pressure controlafter discontinuation of a physician-pharmacist collaborativeintervention. Pharmacotherapy 2010;30:228–35).

2. Carter BL, Bergus GR, Dawson JD, et al. A cluster-randomiza-tion trial to evaluate physician/pharmacist collaboration to improveblood pressure control. J Clin Hypertens 2008;10(4):260–71.

3. McKenney JM, Slining JM, Henderson HR, Devins D, Barr M.The effect of clinical pharmacy services on patients withessential hypertension. Circulation 1973;48:1104–11.

4. Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy careprogram on medication adherence and persistence, blood pres-sure, and low-density lipoprotein cholesterol (a randomizedcontrolled trial). JAMA 2006;296:2563–71.

5. Dickerson LM, Kraus CK, Kuo GM, et al. Formation of aprimary care pharmacist practice-based research network. Am JHealth-Syst Pharm 2007;64:2044–9.

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