Category: Federal Forum Posters
Purpose: Hypertension is the most common chronic condition among veterans, affecting more than a third of the veteran population. To adequately treat hypertensive patients, multiple medication dose adjustments, frequent lab monitoring, non-pharmacologic treatment, and consistent follow up are often required. Primary care providers often have limited clinic availability due to annual follow up appointment, inhibiting the ability for intermittent appointments to optimize care. These intermittent appointments are crucial for medication titration and to ensure adequate blood pressure control. The primary objective of this quality improvement project is to improve hypertension control through the expansion of established clinical pharmacy services.
Methods: This quaility improvement project was approved by the Pharmacy and Therapeutics Committee and deemed IRB approval was not required. Based on data within the Primary Care Almanac, a performance measure tool, patients were included if they had a diagnosis of hypertension, were above blood pressure goal (systolic blood pressure greater than 140 mmHg or diastolic blood pressure greater than 90 mmHg), had a diagnosis of ischemic heart disease, with or without diabetes, and written consent from the provider and patient. Patients were excluded during initial chart review if they had an acute cause of hypertension (i.e. uncontrolled pain, alcohol withdrawal, acute mental health decompensation), medical emergency, already enrolled in the Pharmacotherapy Clinic, or diagnosed with congestive heart failure. The following data was collected during intial chart review: comorbidities, allergies, vitals, labs, and past antihypertensive medications trialed. Upon completion of the intervention window, a final chart review was completed to collect vitals, labs, medication changes, adverse effects, other pharmacy interventions, and medication adherence to analyze the primary and secondary outcomes. The primary outcome was the percentage of patients that met goal blood pressure based on the Department of Veteran Affairs/Department of Defense (VA/DoD) guidelines for hypertension. The secondary outcomes included appropriate medications prescribed following the VA/DoD guidelines, medication adherence, and adverse effects of medications.
Results: Seventeen patient were enrolled into the Pharmacotherapy Clinic to be managed for hypertension. The average age of patient seen in clinic was 71.4 years old. All patient enrolled were males. The average atherosclerotic cardiovascular disease (ASCVD) 10-year risk was 36 percent. At baseline patient most patients were taking aspirin (16), statins (16), beta blockers (11), and angiotensin II receptor blocker (ARBs) (7). Prior to clinic enrollment, the average systolic blood pressure was 150.9 mm Hg and diastolic blood pressure was 81.9 mm Hg. At the completion of the invention window, the average systolic blood pressure was 134.9 mm Hg and diastolic blood pressure was 75.4 mm Hg. Twelve patients were considered at goal upon initial visit when blood pressure was checked manually in clinic by the pharmacist. Ultimately, 82.4 percent of patients met blood pressure at goal and 17.6 percent did not meet blood pressure goal at the completion of clinic. Three medications were initiated in clinic, one medication was titrated up and one medication was tapered off. Eleven patients reported being adherent to their medications and six patients required pharmacist intervention. Adverse drug reactions included two with lisinopril, one with hydrochlorothiazide and one to beta blockers.
Conclusion: Pharmacist intervention led to accurate assessment and documentation of patient’s blood pressures and improved blood pressure control. Continued education is needed to ensure proper blood pressure checks are being performed in clinic by healthcare professionals as the majority of patients were meeting goal when pressures were checked according to recommended procedures. Additionally, proper documentation is essential to allow timely and accurate assessment of the patient and to ensure the facility is meeting national metrics. Further expansion of this project may allow for improved outcomes in the larger population at this facility
Taler Steir– Pharmacist, Sheridan VA Healthcare System, Sheridan, WY