March 19, 2020
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‘Working side by side’: Physician-pharmacist collaborations can improve patient care

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Evan Sisson
Evan M. Sisson

Some of the greatest strains on health care providers — managing numerous patients with CVD, physician burnout, insufficient capacity — have been significantly improved by physician-pharmacist collaborations, according to experts.

Collaborative practice agreements with pharmacists allow physicians to spend more time on diagnosing new problems and achieve better [BP] control rates, which results in overall higher reimbursements,” Evan M. Sisson, PharmD, MSHA, CDCES, FADCES, a professor in the department of pharmacotherapy and outcomes science at Virginia Commonwealth University School of Pharmacy, told Healio Primary Care.

However, experts also said there are significant obstacles hindering uptake of these collaborations.

“There’s some hesitancy behind this model,” Norman Tomaka, BS, PharmMS, FAPhA, pharmacist at Consultant Pharmacist Services in Florida, said in an interview. “Some members of the medical community fear that the collaborations will drive up health care costs, but other countries’ health-outcomes data show it drives down health care costs.”

References: Avery AJ, et al. Lancet; 2012:doi:10.1016/S0140-6736(11)61817-5; Carter BL, et al. J Clin Hypertens (Greenwich). 2008;doi:10.1111/j.1751-7176.2008.0743; Carter BL, et al. Arch Intern Med. 2009;doi:10.1001/archinternmed.2009.316; Carter BL, et al. Arch Intern Med. 2009;doi:10.1001/archinternmed.2009.358; Carter BL, et al. Circ Cardiovasc Qual Outcomes. 2015;doi:10.1161/CIRCOUTCOMES.114.001283; and Carter BL, et al. J Clin Hypertens (Greenwich). 2012;doi:10.1111/j.1751-7176.2011.00542.x.aption here.

Healio Primary Care interviewed experts to better understand how physician-pharmacist collaborations work, how to start those alliances and how to keep them going.

Better patient outcomes

Healio previously reported that 13% of adults in the United States have diabetes. In addition, after adjusting for inflation, researchers found that the economic burden of diabetes grew from $261 billion in 2012 to $327 billion in 2017.

Sisson, a practicing clinician, co-authored a review article more than a decade ago that examined how pharmacists collaborated with physicians to provide care to patients with diabetes.

“Patients with chronic disease, like diabetes, have a long checklist of items that need to be regularly addressed to detect and manage secondary complications,” Sisson said. “This checklist is amplified by the number of patients with diabetes and exacerbated by the fact that they often arrive with new complaints for the physician to address.

He and his co-author found that when a pharmacist provided care and educated patients with diabetes, HbA1c levels lowered by an average of 0.62%, LDL cholesterol and mean systolic BP levels were significantly reduced, and average total health care costs dropped by $1,079 per patient.

The benefits of physician-pharmacist collaborations also were demonstrated about 5 years later, when Sisson and colleagues retrospectively assessed their effect on the time it took nearly 400 uninsured patients with hypertension to reach their target BP. In the study, 259 patients participated in an intervention in which a pharmacist authorized medication initiation and management and monitored their chronic disease. Another 118 patients were assigned a primary care physician, referred to a specialist if needed and were offered low-cost prescription drugs through Medicare’s 340B Drug Discount Program. Researchers found that the median time for patients in the pharmacist-physician collaborative intervention to reach their BP goal was 36 days. Among patients in the usual care model, it took a median of 259 days.

According to Sisson, the significance of those results extend beyond where the study took place, in Virginia.

“The blood pressure control rate of our collaborative care model ranks in the 90th percentile of National Committee for Quality Assurance benchmarks and was superior even to the reported mean for commercial insurers in 2013,” he said.

The American Heart Association has reported that almost half of all U.S. adults have high BP, and worldwide, it is the leading cause of CVD death, adding to the clinical relevance of Sisson and colleagues’ findings.

Barry Carter
Barry L. Carter

In another study, Barry L. Carter, PharmD, professor emeritus at the College of Pharmacy at the University of Iowa, and colleagues studied 32 primary care medical offices throughout the United States that employed clinical pharmacists. Medical offices were randomized to have the pharmacist either limit their professional activity to exclusively performing curbside consultations or to an intervention in which clinical pharmacists provided direct patient care to assist with optimizing medication in order to achieve BP control.

Carter had previously co-authored several studies showing the BP benefits of physician-pharmacist collaborations. However, this study was the first in which a significant proportion of the patient population included minorities. Of the 625 patients aged 46 to 65 years in the study, 239 were black and 89 were Hispanic.

“None of the patients had controlled blood pressure prior to the the study, ,” Carter told Healio Primary Care. “It’s been much more difficult to improve blood pressure in minority populations.”

Carter and colleagues found that, at 9 months, the average systolic BP among participants that received the pharmacist intervention was 6.1 mm Hg lower and diastolic BP was 2.9 mm Hg lower when compared to the curbside consultations group The percentage of patients with controlled hypertension was 43% in the intervention group and 34% in the control group. There were also significant improvements in BP in the minority population.

“These findings suggest that an established team-based care model involving pharmacists can be adopted in a large number of very diverse offices to reduce racial disparities in BP control,” Carter said.

There is also evidence that the physician-pharmacist collaboration model can do more than lower BP and HbA1c levels. Researchers in England looked at how these alliances reduce medication errors — a scenario that a 2018 report attributed to 1 in 131 outpatient deaths and 1 in 854 inpatient deaths in the United States.

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Tony Avery
Anthony J. Avery

Anthony J. Avery, MD, a general practitioner and professor of primary health care at the University of Nottingham in the United Kingdom who has been looking into prescribing errors for about 20 years, led the research project.

“Some of the problems we were picking up involved long-term prescribing and failure to do blood test monitoring in some of these cases,” Avery told Healio Primary Care. “I realized that we could pick up a lot of these patients with our clinical computer systems, but the question was whether this would result in improvements to care given that [pharmacists] simply providing feedback to clinicians is not a particularly effective intervention.”

To answer that question, Avery and colleagues conducted a cluster randomized trial that included 72 general practices in England with 480,942 patients at risk for medication complications. The practices were allocated to either computer-generated feedback that warned about the risks for medication errors (controls) or a pharmacist-led IT intervention called PINCER. In the intervention group, the pharmacist met with members of the practice team to discuss the computer-generated feedback and to help correct the mistake. The researchers compared the number of clinically important medication errors like nonselective NSAIDs that were prescribed to patients with a history of peptic ulcer without a co-prescription of a proton-pump inhibitor; beta blockers prescribed to those with a history of asthma; or long-term prescription of angiotensin-converting enzyme (ACE) inhibitor or loop diuretics to those aged 75 years or older without an assessment of urea and electrolytes in the previous 15 months.

Prescription 
There is evidence that the physician-pharmacist collaboration model can do more than lower BP and HbA1c levels. Researchers in England looked at how these alliances reduce medication errors — a scenario that a 2018 report attributed to 1 in 131 outpatient deaths and 1 in 854 inpatient deaths in the United States.

Photo source: Adobe

Published in 2012, the study showed that after 6 months patients in the PINCER group were significantly less likely than patients in the control group to have been prescribed a nonselective NSAID (OR = 0.58; 95% CI, 0.38-0.89); a beta blocker if they had asthma (OR = 0.73; 95% CI, 0.58-0.91); or an ACE inhibitor or loop diuretic without appropriate monitoring (OR = 0.51; 95% CI, 0.34-0.78). The researchers said the intervention had a 95% probability of being cost-effective if a provider was willing to pay 75 euros (in 2012 currency) to avoid each potential medical error.

“We have demonstrated that the intervention is likely to be cost-effective, and so it is worth doing from the perspective of patients, clinicians and the health care system,” Avery said.

Share the care

The benefits of physician-pharmacist collaborations are not just limited to patients.

After interviewing 16 PCPs, Kylee A. Funk, PharmD, BCPS, a clinical pharmacist and assistant professor at the College of Pharmacy at the University of Minnesota, and colleagues reported in the Journal of the American Board of Family Medicine that these programs:

  • decreased physician workload;
  • increased satisfaction that patients were receiving better care;
  • provided reassurance to physicians;
  • decreased mental exhaustion;
  • enhanced professional learning;
  • increased provider access to patients; and
  • helped physicians achieve quality measures.

Funk told Healio Primary Care that the exorbitant cost of medication-related morbidity and mortality in the U.S. further supports the need for more physician-pharmacist collaborations.

“Medications are becoming more and more complex,” she said. “Not only does comprehensive medication management help patients achieve their goals, but it can also be helpful for providers. Comprehensive medication management offers primary care providers a partner who provides a service that is complementary to their own. Our study demonstrated that primary care providers highly value the PCP-pharmacist partnership.”

At least one study has suggested that physician-pharmacist collaborations may also provide a solution to the shortage of PCPs in the U.S.

In a Health Affairs article, Thomas Bodenheimer, MD, MPH, a professor of family and community medicine at the University of California, San Francisco, and Mark D. Smith, MD, MBA, concluded that if pharmacists provided diabetes-related health coaching and took the lead on initiatives to increase patients’ medication adherence and if other nonphysicians “share the care” within their health system (eg, nonclinician panel members providing U.S. Preventive Services Task Force-recommended care), there would be an almost immediate 10% increase in primary care capacity.

A lot of inertia

For all the benefits that physician-pharmacist collaborations appear to provide, not everyone embraces the idea.

One barrier to greater pharmacist-physician collaboration uptake is that patients do not want to add another medical professional to their contact list, according to Tomaka.

“Patients are less apt to receive preventive health care [and participate] in collaborative practice agreements,” he said. “Many may not present to the health system until a health issue becomes critical.”

Sisson said he disagrees with some of that assessment; that patients seem receptive to the collaborations.

“Patients are more interested in feeling better than [medical] team composition,” he said. “Most patients want their concerns to be heard and for their questions to be answered. Providers, including pharmacists, who listen to their patients are highly regarded by their patients.”

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There is also a lack of consensus on how much physicians are willing to adopt physician-pharmacist alliances in their practices.

A survey of 332 Michigan-based internists, pulmonologists, endocrinologists and cardiologists asked these professionals about their likelihood to collaborate with a pharmacist on a scale of 1 to 7. Seven indicated “very likely.” The average score was 5.32, the survey’s authors reported.

Tomaka said not all physicians are not embracing collaboration with pharmacists to the extent the survey suggests.

Two Medical Professionals Talking 
“Some physicians want pharmacists to stay on the pharmacists’ part of the silo,” a pharmacist said. “That mentality is probably one of the biggest barriers to these collaborations becoming more common.”

Photo Source:Adobe

“Some physicians want pharmacists to stay on the pharmacists’ part of the silo,” he said. “That mentality is probably one of the biggest barriers to these collaborations becoming more common.”

Carter disagreed, suggesting that physicians are becoming more accepting of collaborative care agreements.

“Pharmacists were rarely considered as possible solutions to gaps in chronic disease control in past,” he said. “However, at national society meetings such as the American Heart Association, or when convening expert guideline committees, collaborating with pharmacists is frequently mentioned as an important strategy to improve care,” Carter said. “The medical community, particularly primary care, is very supportive of this initiative and there are now some [non-federal] payment structures emerging for pharmacists who are embedded within medical offices.”

Jeffrey McCombs
Jeff McCombs

According to Jeff McCombs, PhD, an associate professor of pharmaceutical and health economics at the University of Southern California School of Pharmacy, reimbursement is another major challenge.

“There will be some aggressive resistance on the part of insurance providers to use fee-for service-based payment for pharmacy services, providers,” McCombs said in an interview.

“Health insurance companies and government programs are extremely reluctant to pay the community pharmacy for professional services based on a simple fee-for-service system,” he said. “Payer concerns stem from the long history of physician abuse of fee-for-service payment systems under which the patient’s need for the service was impossible to verify, the outcome of the service was questionable and a reasonable price for the service was impossible to establish.” McCombs added that pay-for-performance methods are gaining acceptance to address this problem.

McCombs pointed to a study in Obstetrics & Gynecology to illustrate his point. Researchers noted that California pharmacists can provide contraception medications without a physician’s prescription, but a “secret shopper” assessment found that only 5% the 457 pharmacies did. Most of those who did not provide the service cited the uncertainty regarding reimbursement.

Carter agreed that the lack of a consensus among stakeholders regarding the value that physician-pharmacist collaborations bring to the medical profession has blocked the development of a federal payment model.

“There’s a mismatch between the physician and in the trenches and organizations and bureaucracies that are yet to be convinced, even though I think they are much more aware now of the value of pharmacists,” he said. “I have hope that a [federal] payment model will become a reality, but it’s hard to say if it will ever really happen.”

McCombs said he has met with insurance companies and educational institutions and published several white papers during the past decade, trying to convince relevant parties about the collaboration’s benefits and experiment with pay-for-performance systems. He said technological barriers could be to blame for the hesitancy to establish a federal payment model.

“To receive payment, the pharmacy must have the capability to assess and report the clinical outcomes in an accurate and verifiable manner rather than relying on pharmacists’ billing for consultations, phone calls and refill reminders,” he said. “Some clinical assessments may be beyond the capabilities of the pharmacist, such as administering mental health assessment instruments or knowing when an asthma patient accesses the ER or urgent care for breakthrough symptoms.”

For pharmacists to get involved in these collaborations, they would need access to the patient’s electronic medical record,” McCombs said.

“Though that can be a little hard to do if you’re dealing with multiple different health systems, it’s not insurmountable by any means,” he said.

McCombs said the low uptake of physician-pharmacist collaborations is frustrating.

“There’s just a lot of inertia,” he said. “And I’m kind of disappointed that the academic community doesn’t seem to be particularly interested.”

Tomaka said the CDC has published “a ton” of material on physician-pharmacist collaborations, suggesting that a federal payment model may be imminent. However, proponents need to speak up.

“Drug therapy over the past 40 years has gone from pretty nonspecific, to mild, to we now have very potent drugs, very specific receptor therapy drugs, where pharmacists are the only ones that can figure out inappropriate or dangerous use,” he said. “While it makes sense to have formalized collaboration process, we need a lot of foot soldiers to become reality.”

Getting started

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2017 guidance from the CDC indicates that physician-pharmacist collaborations can occur in primary care offices or clinics, long-term care facilities, specialty clinics and other health care environments.

“Each of these practice settings has its own nuances, challenges and opportunities,” the agency stated.

The AMA provides multiple suggestions on its website to help physicians weigh the pros and cons of creating a physician-pharmacist collaboration.

Avery said that at time when his 2012 study was published, many of his peers were skeptical of physician-pharmacist collaborations. However, much of that doubt has subsided.

 

“There were concerns about the value of the intervention and its effect on workload,” he said. “But we have the positive results from the study and the pharmacists are trained in educational outreach so that they are able to provide evidence-based responses to queries from the family practitioners. The intervention has relatively little impact on family practitioners since pharmacists do much of the work.”

He noted that since the article was published, more than 60% of the general medical practices in England have participated in a collaboration with a pharmacist, with most of the remaining practices expected to participate in 2021. In addition, more than 1,000 pharmacists in England have been trained to deliver the intervention.

Sisson said that once the relationship between physicians and pharmacists is established, collaborative care agreements become “much easier” to maintain.

“The physician and pharmacist should start small by working side by side in a clinic,” he said. “Physicians can delegate medication follow-up to the pharmacist and ask for regular reports. As the relationship grows, so will the level of trust and responsibility. Ultimately, a true bidirectional collaborative relationship will form,” he said. – by Janel Miller

References:

AHA. More than 100 million Americans have high blood pressure, AHA says. https://www.heart.org/en/news/2018/05/01/more-than-100-million-americans-have-high-blood-pressure-aha-says. Jan. 31, 2018. Accessed Feb. 22, 2020.

AMA. How to make the pharmacist part of your practice’s team. https://www.ama-assn.org/practice-management/payment-delivery-models/how-make-pharmacist-part-your-practice-s-team. July 14, 2017. Accessed Jan. 23, 2020.

Avery AJ, et al. Lancet; 2012:doi:10.1016/S0140-6736(11)61817-5.

Batra P, et al. Obstet Gynecol. 2018;doi:10.1097/AOG.0000000000002572.

Bodenheimer TS, et al. Health Aff (Millwood). 2013;doi:10.1377/hlthaff.2013.0234.

Carter BL, et al. J Clin Hypertens (Greenwich). 2008;doi:10.1111/j.1751-7176.2008.0743.

Carter BL, et al. Arch Intern Med. 2009;doi:10.1001/archinternmed.2009.316.

Carter BL, et al. Arch Intern Med. 2009;doi:10.1001/archinternmed.2009.358.

Carter BL, et al. Circ Cardiovasc Qual Outcomes. 2015;doi:10.1161/CIRCOUTCOMES.114.001283.

Carter BL, et al. J Clin Hypertens (Greenwich). 2012;doi:10.1111/j.1751-7176.2011.00542.x.

CDC. Advancing team-based care through collaborative practice agreements. https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team-Based-Care.pdf. Accessed March 4, 2020.

Dixon DL, et al. J Clin Hypertens (Greenwich). 2018;doi:10.1111/jch.13150.

Funk KA, et al. J Am Board Fam Med. 2019;doi.10.3122/jabfm.2019.04.180376.

Kucukarslan S, et al. Res Social Adm Pharm. 2011;doi:10.1016/j.sapharm.2010.07.003.

Linzer M, et al. J Gen Intern Med. 2015;doi:10.1007/s11606-015-3341-3.

Munther P, et al. Hypertension. 2017;doi:10.1161/HYPERTENSIONAHA.117.09061.

Polgreen LA, et al. Hypertension. 2015;doi:10.1161/HYPERTENSIONAHA.115.06023.

Sisson E, et al. J Am Pharm Assoc. 2009;doi:10.1331/JAPhA.2009.09075.

Sisson EM, et al. Pharmacotherapy. 2016;doi:10.1002/phar.1710.

Watanabe JH, et al. Ann Pharmacother. 2018;doi:10.1177/1060028018765159.

Zhang D, et al. Am J Prev Med. 2017;doi:10.1016/j.amepre.2017.05.014.

Zhou S, et al. AMIA Annu Symp Proc. 2018:1611-1620.

Disclosures: Avery, Carter, Funk, McCombs, Sisson and Tomaka report no relevant financial disclosures.