Collaborative hypertension case management by clinical pharmacy specialists and registered nurses in a VA primary care clinic

Purpose: This study evaluated a novel care model of collaborative case management with clinical pharmacy specialists (CPSs) and registered nurse (RN) case managers. The primary objective was to establish non-inferiority of CPS-directed RN case management of hypertension (HTN) versus the usual model of physician-directed RN case management in the Veterans Affairs Ann Arbor Healthcare System primary care clinic.

Methods: Medical records between 9/20/2011 and 10/31/2011 were used to identify patients who attended RN hypertension case management appointments. The sample included 126 patients whose medical decision-making was directed by a CPS (n=63) or physician (n=63). The difference in systolic blood pressure (SBP) between index and the next consecutive visit was collected for each patient. The following variables were also collected: sex, smoking status, age, BMI, comorbidities, number of antihypertensive medications, home blood pressure cuff prescriptions, time between visits, and referrals provided at the visit.

Results: Demographic data were similar between groups. Patients in both groups had significantly lower mean SBP at follow-up (135 ±13 mmHg) compared to the initial visit (147±11mmHg). Patients receiving CPS-directed HTN case management had greater average decreases in SBP compared to those receiving physician-directed care (14±13mmHg versus 10±11mmHg; p<0.05). After adjusting for the amount of time between visits, initial SBP, and smoking status, provider type was no longer significant(p=0.177). Patients with higher initial SBP had greater SBP reduction at the follow-up visit(p<0.001).

Conclusion: Collaborative HTN case management by clinical pharmacy specialists and RNs is a novel model of care, which was non-inferior to physician-directed RN case management. Clinically significant blood pressure reductions occurred in both the CPS- and physician-directed RN case management groups. Baseline SBP was a predictor of SBP change; this may be due to regression to the mean.  This represents an expanded role for clinical pharmacy specialists in ambulatory care clinics.