Implementation and evaluation of a pharmacist-led hypertension management service in primary care: outcomes and methodological challenges

Main Article Content


Hypertension, Community Pharmacy Services, Interprofessional Relations, Medication Adherence, Medication Therapy Management, Methodology, Australia


Background: Suboptimal utilisation of pharmacotherapy, non-adherence to prescribed treatment, and a lack of monitoring all contribute to poor blood (BP) pressure control in patients with hypertension.

Objective: The objective of this study was to evaluate the implementation of a pharmacist-led hypertension management service in terms of processes, outcomes, and methodological challenges.

Method: A prospective, controlled study was undertaken within the Australian primary care setting. Community pharmacists were recruited to one of three study groups: Group A (Control – usual care), Group B (Intervention), or Group C (Short Intervention). Pharmacists in Groups B and C delivered a service comprising screening and monitoring of BP, as well as addressing poor BP control through therapeutic adjustment and adherence strategies. Pharmacists in Group C delivered the shortened version of the service.

Results: Significant changes to key outcome measures were observed in Group C: reduction in systolic and diastolic BPs at the 3-month visit (P<0.01 and P<0.01, respectively), improvement in medication adherence scores (P=0.01), and a slight improvement in quality of life (EQ-5D-3L Index) scores (P=0.91). There were no significant changes in Group B (the full intervention), and no differences in comparison to Group A (usual care). Pharmacists fed-back that patient recruitment was a key barrier to service implementation, highlighting the methodological implications of screening.

Conclusion: A collaborative, pharmacist-led hypertension management service can help monitor BP, improve medication adherence, and optimise therapy in a step-wise approach. However, blood pressure screening can effect behaviour change in patients, presenting methodological challenges in the evaluation of services in this context.

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1. Chow CK, Teo KK, Rangarajan S, Islam S, Gupta R, Avezum A, Bahonar A, Chifamba J, Dagenais G, Diaz R, Kazmi K, Lanas F, Wei L, Lopez-Jaramillo P, Fanghong L, Ismail NH, Puoane T, Rosengren A, Szuba A, Temizhan A, Wielgosz A, Yusuf R, Yusufali A, McKee M, Liu L, Mony P, Yusuf S; PURE (Prospective Urban Rural Epidemiology) Study investigators. PRevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA. 2013;310(9):959-968. doi: 10.1001/jama.2013.184182

2. Ho PM, Magid DJ, Shetterly SM, Olson KL, Peterson PN, Masoudi FA, Rumsfeld JS. Importance of therapy intensification and medication nonadherence for blood pressure control in patients with coronary disease. Arch Intern Med. 2008;168(3):271-276. doi: 10.1001/archinternmed.2007.72

3. Janus ED, Bunker SJ, Kilkkinen A, Mc Namara K, Philpot B, Tideman P, Tirimacco R, Laatikainen TK, Heistaro S, Dunbar JA. Prevalence, detection and drug treatment of hypertension in a rural Australian population: the Greater Green Triangle risk factor study 2004-2006. Intern Med J. 2008;38(12):879-886. doi: 10.1111/j.1445-5994.2007.01583.x

4. Lebeau JP, Cadwallader JS, Aubin-Auger I, Mercier A, Pasquet T, Rusch E, Hendrickx K, Vermeire E. The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review. BMC Fam Pract. 2014;15:130. doi: 10.1186/1471-2296-15-130

5. Peterson G, Jackson S, Hughes J, Fitzmaurice K, Murphy L. Public perceptions of the role of Australian pharmacists in cardiovascular disease. J Clin Pharm Ther. 2010;35(6):671-677. doi: 10.1111/j.1365-2710.2009.01139.x

6. Castelino RL, Bajorek BV, Chen TF. Targeting suboptimal prescribing in the elderly: a review of the impact of pharmacy services. Ann Pharmacother. 2009;43(6):1096-1106. doi: 10.1345/aph.1L700

7. Castelino RL, Bajorek BV, Chen TF. Retrospective evaluation of home medicines review by pharmacists in older australian patients using the medication appropriateness index. Ann Pharmacother. 2010;44(12):1922-1929. doi: 10.1345/aph.1P373

8. Castelino RL, Chen TF, Guddattu V, Bajorek BV. Use of evidence-based therapy for the prevention of cardiovascular events among older people. Eval Health Prof. 2010;33(3):276-301. doi: 10.1177/0163278710374854

9. Bajorek B, Lemay K, Magin P, Roberts C, Krass I, Armour C. Preparing pharmacists to deliver a targeted service in hypertension management: evaluation of an interprofessional training program. BMC Med Educ. 2015;15:157. doi: 10.1186/s12909-015-0434-y

10. Krass I, Hebing R, Mitchell B, Hughes J, Peterson G, Song YJ, Stewart K, Armour CL. Diabetes management in an Australian primary care population. J Clin Pharm Ther. 2011;36(6):664-672. doi: 10.1111/j.1365-2710.2010.01221.x

11. Armour C1, Bosnic-Anticevich S, Brillant M, Burton D, Emmerton L, Krass I, Saini B, Smith L, Stewart K. Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community. Thorax. 2007 Jun;62(6):496-502.

12. Nemerovski C, Young M, Mariani N, Bugdalski-Stutrud C, Moser L. Project ImPACT: Hypertension Outcomes of a Pharmacist-Provided Hypertension Service. Innovations in Pharmacy. 2013;4(3):126.

13. Libby EA, Laub JJ. Economic and clinical impact of a pharmacy-based antihypertensive replacement program in primary care. Am J Health Syst Pharm. 1997;54(18):2079-2083.

14. Erickson SR, Slaughter R, Halapy H. Pharmacists' ability to influence outcomes of hypertension therapy. Pharmacotherapy. 1997;17(1):140-147.

15. Carter BL, Malone DC, Billups SJ, Valuck RJ, Barnette DJ, Sintek CD, Ellis S, Covey D, Mason B, Jue S, Carmichael J, Guthrie K, Dombrowski R, Geraets DR, Amato M; Impact of Managed Pharmaceutical care on resource utilization and Outcomes in Veterans affairs medical centers. Interpreting the findings of the IMPROVE study. Am J Health Syst Pharm. 2001 Jul 15;58(14):1330-1337.

16. Glynn LG, Murphy AW, Smith SM, Schroeder K, Fahey T. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev. 2010;(3):CD005182. doi: 10.1002/14651858.CD005182.pub4

17. Uhlig K, Patel K, Ip S, Kitsios GD, Balk EM. Self-measured blood pressure monitoring in the management of hypertension: a systematic review and meta-analysis. Ann Intern Med. 2013;159(3):185-194. doi: 10.7326/0003-4819-159-3-201308060-00008

18. Tsuyuki RT, Houle SK, Charrois TL, Kolber MR, Rosenthal MM, Lewanczuk R, Campbell NR, Cooney D, McAlister FA; RxACTION Investigators. Randomized Trial of the Effect of Pharmacist Prescribing on Improving Blood Pressure in the Community: The Alberta Clinical Trial in Optimizing Hypertension (RxACTION). Circulation. 2015;132(2):93-100. doi: 10.1161/CIRCULATIONAHA.115.015464

19. Krass I, Bajorek B. Pharmacists’ therapeutic recommendations in the management of hypertension in primary care. National Medicines Symposium, Sydney (Australia). June 2012.

20. National Heart Foundation of Australia (National Blood Pressure and Vascular Disease Advisory Committee). Guide to Management of Hypertension 2008 (Updated December 2010). ISBN: 978-1-921226-85-4, (xccessed November 1, 2014).

21. National Heart Foundation of Australia (Aslani P KI, Bajorek B, Thistlewaite J, Tofler G, on behalf of the Heart Foundation Pharmaceutical Roundtable). Improving adherence in cardiovascular care. A toolkit for health professionals. http://wwwheartfoundationorgau/SiteCollectionDocuments/Improving-adherence-in-cardiovascular-care-toolkit.pdf (accessed August 4, 2014).

22. Health Workforce Australia. Health Professionals Prescribing Pathway project. Available from: (accessed June 29, 2015).

23. Hoti K, Hughes J, Sunderland B. An expanded prescribing role for pharmacists - an Australian perspective. Australas Med J. 2011;4(4):236-242. doi: 10.4066/AMJ.2011.694

24. Lau R, Stewart K, McNamara KP, Jackson SL, Hughes JD, Peterson GM, Bortoletto DA, McDowell J, Bailey MJ, Hsueh A, George J. Evaluation of a community pharmacy-based intervention for improving patient adherence to antihypertensives: a randomised controlled trial. BMC Health Serv Res. 2010;10:34. doi: 10.1186/1472-6963-10-34

25. Torgerson D. Contamination in trials: is cluster randomisation the answer? BMJ. 2001;322(7282):355-357.doi: 10.1136/bmj.322.7282.355

26. Svarstad B, Bultman D. Remington:The Science and Practice of Pharmacy. The patient: Behavioral determinants. Baltimore: Lippincott Williams & Wilkins; 2000.

27. Australian Government - Cancer Australia. Principles of shared care (shared follow-up care), 2013. Available at: (cccessed March 31, 2016).

28. Pharmaceutical Society of Australia. Standard and guidelines for pharmacists performing clinical interventions. Deakin West, ACT (Australia), 2011.

29. Morisky D, Ang A, Krousel-Wood M, Ward H. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich). 2008;10(5):348-354.

30. Krousel-Wood M, Islam T, Webber L, Re R, Morisky D, Muntner P. New medication adherence scale versus pharmacy fill rates in seniors with hypertension. Am J Manag Care. 2009;15(1):59-66.

31. Morisky D, DiMatteo M. Improving the measurement of self-reported medication nonadherence: Final response. J Clin Epidemiol. 2011;64(3):255-257. doi: 10.1016/j.jclinepi.2010.09.002

32. Dolan P. Modelling valuations for EuroQol health states. Medical Care. 1997;35(11):1095-1108.

33. EuroQol Group. EuroQol-a new facility for the measurement of health-related quality of life. Health Policy. 1990;16(3):199-208.

34. Brooks R. EuroQol: the current state of play. Health Policy. 1996;37(1):53-72.

35. Machado M, Bajcar J, Guzzo GC, Einarson TR. Sensitivity of patient outcomes to pharmacist interventions. Part II: Systematic reviews and meta-analysis in hypertension management. Ann Pharmacother. 2007;41(11):1770-1181.

36. McLean DL, McAlister FA, Johnson JA, King KM, Makowsky MJ, Jones CA, Tsuyuki RT; SCRIP-HTN Investigators. A randomized trial of the effect of community pharmacist and nurse care on improving blood pressure management in patients with diabetes mellitus: Study of cardiovascular risk intervention by pharmacists–hypertension (SCRIP-HTN). Arch Intern Med. 2008;168(21):2355-2361. doi: 10.1001/archinte.168.21.2355

37. IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp.

38. EQ-5D value sets: Inventory craug. EuroQol Group Monographs. Szende A OM, Devlin N, ed: Springer; 2006.

39. Thomas D. A general inductive approach for analyzing qualitative evaluation data. Am J Eval. 2006;27(2):237-246. doi: 10.1177/1098214005283748

40. Bauman A, Nutbeam D. Planning and evaluating population interventions to reduce noncommunicable disease risk - reconciling complexity and scientific rigour? Public Health Res Pract. 2014;25(1). doi: 10.17061/phrp2511402

41. Muntner P, Joyce C, Holt E, He J, Morisky D, Webber LS, Krousel-Wood M. Defining the minimal detectable change in scores on the 8-item Morisky Medication Adherence Scale. Ann Pharmacother. 2011;45(5):569-575. doi: 10.1345/aph.1P677

42. Guirguis LM, Johnson JA, Farris KB, Tsuyuki RT, Toth EL. A pilot study to evaluate the impact of pharmacists as certified diabetes educators on the clinical and humanistic outcomes of people with diabetes. Can J Diab Care. 2001;25(4):266-276.

43. Deutekom M, Vansenne F, McCaffery K, Essink-Bot M-L, Stronks K, Bossuyt P. The effects of screening on health behaviour: a summary of the results of randomized controlled trials. J Public Health (Oxf). 2011;33(1):71-79. doi: 10.1093/pubmed/fdq050

44. Tsuyuki RT, Houle SK, Charrois TL, Kolber MR, Rosenthal MM, Lewanczuk R, Campbell NR, Cooney D McAlister FA; RxACTION Investigators. A randomized trial of the effect of pharmacist prescribing on improving blood pressure in the community: the Alberta clinical trial in optimizing hypertension (RxACTION). Circulation. 2015;132(2):93-100. doi: 10.1161/CIRCULATIONAHA.115.015464

45. Chabot I, Moisan J, Gregoire JP, Milot A. Pharmacist intervention program for control of hypertension. Ann Pharmacother. 2003;37(9):1186-1193.

46. Zillich AJ, Sutherland JM, Kumbera PA, Carter BL. Hypertension outcomes through blood pressure monitoring and evaluation by pharmacists (HOME study). J Gen Intern Med. 2005 Dec;20(12):1091-1096.

47. McGhan WF, Stimmel GL, Hall TG, Gilman TM. A comparison of pharmacists and physicians on the quality of prescribing for ambulatory hypertensive patients. Med Care. 1983;21(4):435-444.

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