Pharmacists have had a known impact in primary care practices and clinics for a variety of disease states and conditions. In addition, pharmacists can serve as physician extenders within a primary care clinic to provide pharmaceutical care with direct compensation. Over the past two years, the Patient-Center Medical Home (PCMH) has been the new term in the medical word – a new approach to patient care within the primary care setting to tackle the rising prevalence of chronic diseases, such as diabetes.1 Within the PCMH, pharmacists can have the opportunity to practice the skill of medication therapy management (MTM) services within a physician office.
Pape and colleagues performed a two-year prospective, cluster randomized controlled trial to evaluate the impact of physician-pharmacist team-based care on cholesterol levels in participants with diabetes mellitus. The study was conducted in Oregon within the Providence Primary Care Research Network (PPCRN) at 16 clinics. Clinics were randomized in a 1:2 intervention:control schedule using cluster allocation. The control arm had access to a disease management health information technology (IT) resource and received 2 hours of training. The intervention arm had the health IT resources and implemented the team-based care approach for the management of cholesterol. Participants were at least 18 years of age and had a diagnosis of diabetes mellitus. A pharmacy practitioner would review patient charts with elevated LDL-C. The pharmacist developed evidence-based treatment recommendations, which included medication therapy and follow-up laboratory monitoring. These plans were sent to physicians, which were either approved or ignored. Once approved, the pharmacist contacted the patient via telephone to discuss their role as a practitioner, the patient’s medication history, previous adverse reactions, and identifying barriers to therapy. Education was also provided to the patient to support a shared decision making process regarding the plan to therapy. All patient interactions were documented in the medical chart, signed by the pharmacist, and co-signed by the physician. The primary outcome was the proportion of patients achieving an LDL-C level of 100mg/dL or lower. This included the difference in mean LDL-C between treatment arms at the end of the study, proportion of patients with LDL-C laboratory test within the last 12 months, and proportion of patients prescribed lipid lowering agents. Secondary outcomes included glycemic and blood pressure control.2
A total of 6,963 patients were assessed in the study, of which 4,424 were continuously enrolled throughout the study (2,928 in the control arm and 1496 in the intervention arm). In the intervention arm, 1,527 patients were identified with elevated LDL-C, but only 1,364 patients were appropriate for aggressive LDL-C therapy. From these patients, 514 received management from a pharmacist via telephone-shared decision-making. Only 37 patients declined the pharmacist treatment recommendations. After a 2-year follow-up, 78% percent of patients in the intervention arm and 50% of patients in the control arm achieved target LDL-C (p=0.003). The mean LDL-C was 12mg/dL lower (p<0.001) in the intervention arm (83mg/dL) compared to the control arm (95mg/dL). When looking at LDL-C laboratory tests in the last 12 months, 82% of the treatment arm and 63% of the control arm achieved the LDL-C goal (p=0.009). Patients in the intervention arm were also 15% more likely to receive a prescription for a lipid-lowering agent (p=0.008). There was no significant difference in the secondary outcomes between the treatment arms.2
Based on this study, it can be concluded that off-site pharmacists ...