Pharmacists Can Take an Active Role in Lowering CV Risk Factors, Likelihood of Events

When community pharmacists have the opportunity to regularly engage with patients at high risk for cardiovascular disease, the patients see a positive effect on risk factors such as high systolic blood pressure and LDL cholesterol. Patients had a 21% relative reduction—amounting to a 5% absolute reduction—in their estimated risk of experiencing a CV event, according to new data from a randomized controlled trial.

Implications. Pharmacists Can Take an Active Role in Lowering CV Risk Factors, Likelihood of Events

The RxEACH study, published in the June 21, 2016, issue of the Journal of the American College of Cardiology, suggests that increasing involvement by pharmacists in patient care can lessen the work load on physicians and lead to better outcomes for patients.

“The point of this study is generally a lot of healthcare interventions are bottle necked by physicians or people under direct supervision by the physicians,” Mintu Turakhia, MD (Stanford University, Palo Alto, CA), who was not involved in the research, told TCTMD. And with this approach, he said, “you can get good meaningful outcomes.”

The Pharmacist Will See You Now

Lead author Ross Tsuyuki, PharmD (University of Alberta, Edmonton, Canada), and his colleagues approached 56 community pharmacies and asked them to participate in the randomized trial. Each pharmacist was trained on specific invention practices, then they were asked to recruit patients at high risk of cardiovascular disease to participate in the study. In total, 723 patients were enrolled in the trial, with 370 randomly selected to receive additional pharmacist interventions. The study lasted for 3 months. 

Patients in the intervention group regularly received additional care at least every 3 to 4 weeks in the form of blood pressure, weight, and height measurements as well as laboratory assessments of HbA and fasting cholesterol. While meeting together, pharmacists and patients used an online educational tool created by the study authors to show individualized risks as well as set targets for improving the patient’s health. Pharmacists could also make prescription changes to meet the patient’s needs while providing up-to-date treatment recommendations.

After 3 months, there was a 5% absolute reduction in CV event risk—estimated based on the highest among the Framingham, International, and United Kingdom Diabetes Study risk scores—for patients randomized to extra pharmacy care.

This group showed significantly greater improvements versus baseline in mean levels of LDL cholesterol (-0.2 mmol/L), systolic blood pressure (-9.37 mm Hg), diastolic blood pressure (-2.92 mm Hg), and glycosylated hemoglobin (-0.92%) compared with the control group. Moreover, patients who received the intensive care at their pharmacy were 20.2% more likely to stop smoking than were those who had standard care (P = 0.002).

Too Good To Wait

RxEACH lasted for just 3 months in large part to calls from participating pharmacists expressing concern for their patients in the standard care control group, according to the researchers. In their paper, Tsuyuki et al say they decided to keep the length of the trial short to accommodate those requests, and because they believed the results after 3 months were sufficient.

Had the study continued longer, Tsuyuki predicted, “blood sugar control, blood pressure and cholesterol would [have continued] to improve. Our 3-month evaluation probably underestimated the impact of the pharmacist intervention.”

A complicating factor in interpreting the trial, according to both Tsuyuki and outside experts, is that it was conducted in the publicly funded healthcare system of Alberta, Canada, where pharmacists could receive compensation for the additional time spent working with patients to take measurements, review results, and discuss future adjustments.

The intensity of care wouldn’t be viable in the United States, because pharmacists here are not considered providers, note Larry Weinrauch, MD, Alissa Segal, PharmD, and John D’Elia, MD (Harvard Medical School, Boston, MA), in an accompanying editorial.

Tsuyuki said he understands the trepidation, but that he believes that finding real-world solutions to major health concerns is the bigger issue.

“There are always barriers to change. People need to remember that it is the patient that comes first,” he told TCTMD. “As you know, cardiovascular disease is a major public health problem. We have shown that you could have 400,000 allies to help in this fight. I would hope that the public health benefits would outweigh any issues of ‘turf’ or legislative hurdles. Put another way, if policymakers are truly serious about preventing cardiovascular disease, then expanding scopes of practice to empower pharmacists should be strongly considered.”

Pharmacists in the United States have also been looking for more inclusion in standard patient care, said Craig Beavers, PharmD (University of Kentucky College of Pharmacy, Lexington, KY), who thinks Tsuyuki and his team are onto something.

“He's made a nice model to try to emulate that has some success in the community setting,” he told TCTMD. “And I really think the nice thing [is that] by tying the community pharmacist back to the patient and the provider allows a nice, natural bridge.”

Help Wanted?

The hope of Tsuyuki and others is that the evidence will show how much more pharmacists can contribute to the healthcare process for a patient. The additional intervention from pharmacists could lead to better overall outcomes and healthier patients in the long run rather than just adding another cook to the kitchen, according to Beavers.

“I think the concern, especially from the physician standpoint, is that we're encroaching on their territory and that we are going to take over from their job,” he said. “Really we are trying to make it a team approach, where we utilize the pharmacist to optimize the team to make sure that you have a medication expert on your team that can monitor adverse drug events, make those changes, [and] monitor labs or do some of those types of activities that would be inefficient for a doctor or a nurse practitioner to do.”

The possibility that pharmacists could take over some responsibilities of physicians was addressed in RxEACH by requiring both of the providers to regularly communicate. The systems for collaboration in the trial were mostly already established before Tsuyuki and his team approached the participating physicians and pharmacists, but he emphasized that open lines of communication could be crucial to success.

Turakhia, a cardiac electrophysiologist with research experience in pharmacist intervention, said that pharmacists’ inclusion in care is key.

“Fundamentally,” he said, the future of healthcare will be compartmentalization—“not relying on the physician to cover all of these different domains of care, but rather to stick with diagnostic and therapeutic decision and leave the execution to other parts of the healthcare team.”

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Michael H. Wilson is the recipient of the 2016 Jason Kahn Fellowship in Medical Journalism, working as a summer intern…

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  • Tsuyuki RT, Al Hamarneh YN, Jones CA, Hemmelgarn BR. The effectiveness of pharmacist interventions on cardiovascular risk: the multicenter randomized controlled RxEACH trial. J Am Coll Cardiol. 2016;67:2846-2854.

  • Weinrauch LA, Segal AR, D’Elia JA. Cardiovascular risk reduction and the community pharmacist. J Am Coll Cardiol. 2016;67:2855-2857.

  • Funding for the RxEACH study was provided by Alberta Health and by the Cardiovascular Health and Stroke Strategic Clinical Network of Alberta Health Services.
  • Tsuyuki reports receiving investigator-initiated research grants from Merck, Sanofi, and AstraZeneca, and has served as a consultant for Merck.
  • Segal reports serving on the advisory board for Lilly USA.
  • Turakhia reports receiving research funding from Janssen Pharmaceuticals and serving as a consultant to Boehringer Ingelheim.
  • Beavers, Weinrauch, and D’Elia report no relevant conflicts of interest.