EDITORIAL
Pharmacists in Primary Care SEE RELATED ARTICLE p. 539
It is estimated that there will be a continued shortage of primary care physicians in the years to come. Even if this situation improves regarding numbers, a maldistribution of physicians, especially in rural or economically deprived parts of the country, will remain a problem. For years, the US military healthcare system has been involved in using alternative practitioner models to provide care for patients, especially those with chronic medical conditions such as systemic hypertension, diabetes mellitus, and hyperlipidemia. During my active duty years in the US military medical corps, I observed that one physician could successfully supervise 10 medics in providing excellent primary care of patients with specific conditions. As an outgrowth of the military experience using highly trained medics as primary care providers, the physician assistant and nurse practitioner professions were developed. Physician assistants and nurse practitioners working under the supervision of, or in collaboration with, physicians are now involved in the outpatient follow-up of patients,1 medication titrations and initiation, patient education, and consultations. In the inpatient setting, their duties include taking histories and performing physical examinations, making follow-up rounds, and helping to manage patients in the general wards and intensive care units. In this issue of The American Journal of Medicine, Zillich et al2 demonstrate the utility and effectiveness of using pharmacists in the long-term management of systemic hypertension, demonstrating their success in blood pressure control and treatment compliance in a veterans medical home model of primary care. Pharmacists met individually with patients, adjusted medications when necessary, and provided patient education. One might expect that pharmacists, with their knowledge of medications, would enhance patient treatment adherence and reduce the side effects of Funding: None. Conflict of Interest: None. Authorship: The author had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to William H. Frishman, MD, MACP, Department of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY 10595. E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.11.021
therapy. These professionals also may provide a more costeffective approach to blood pressure management. Schools of Pharmacy now require a Doctor of Pharmacy degree, with more rigorous training than in the past, including rotations in clinical pharmacy. Our own university has 2 schools of pharmacy. We have had clinical pharmacists round with us in the hospital and in our clinics, and their expertise has led to better drug selections, increased patient compliance, and a reduction in adverse reactions from therapy. Beyond the long-term treatment of hypertension as described by Zillich et al2 and others,3,4 one can envision pharmacists being involved in the long-term drug management of conditions such as hyperlipidemia, congestive heart failure, diabetes mellitus,5 and asthma.6 They could help in anticoagulation clinics,7,8 cigarette smoking cessation clinics, and immunization programs.9 Of course, the treatment protocols the pharmacists use need to be evidencebased, under the supervision of a physician. With better use of our allied health care professional groups, such as pharmacists, in a collaborative spirit that is patient centered, the national gap in primary care needs in the United States can be reduced considerably. At the same time, there should be greater patient drug adherence,10 fewer drugedrug interactions and drug side effects, and, ultimately, better clinical outcomes. However, this needs to be studied in clinical trials evaluating different primary treatment care models. William H. Frishman, MD Department of Medicine New York Medical College New York, NY Supplements Editor The American Journal of Medicine
References 1. Shaw RJ, McDuffle JR, Hendrix CC, et al. Effects of NurseManaged Protocols in the Outpatient Management of Adults with Chronic Conditions. Washington, DC: Department of Veterans Affairs; 2013. 2. Zillich AJ, Jaynes HA, Bex SD, et al. Evaluation of pharmacist care for hypertension in the Veterans Affairs patient centered home. Am J Med. 2015;128:539.e1-539.e6.
444 3. Hirsch JD, Steers N, Adler DS, et al. Primary care-based, pharmacistphysician collaborative medication-therapy management of hypertension: a randomized, pragmatic trial. Clin Ther. 2014;36:1244-1254. 4. Houle SK, Chatterley T, Tsuyuki RT. Multidisciplinary approaches to the management of high blood pressure. Curr Opin Cardiol. 2014;29: 344-353. 5. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:173-184. 6. Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic and economic outcomes of a community-based medication therapy management program for asthma. J Am Pharm Assoc. 2006;46: 133-147.
The American Journal of Medicine, Vol 128, No 5, May 2015 7. Chilipko AA, Norwood DK. Evaluating warfarin management by pharmacists in a community teaching hospital. Consult Pharm. 2014;29:95-103. 8. Maynard G, Humber D, Jenkins I. Multidisciplinary initiative to improve inpatient anticoagulation and management of venous thromboembolism. Am J Health Syst Pharm. 2014;71:305-310. 9. Bounthavong M, Christopher ML, Mendes MA, et al. Measuring patient satisfaction in the Pharmacy Specialty Immunization Clinic: a pharmacist-run immunization clinic at the Veterans Affairs San Diego Healthcare System. Intl J Pharm Pract. 2010;18:100-107. 10. Fischer MA, Choudhry NK, Bykov K, et al. Pharmacy-based interventions to reduce primary medication nonadherence to cardiovascular medications. Med Care. 2014;52:1050-1054.
Pharmacists in Primary Care SEE RELATED ARTICLE p. 539
It is estimated that there will be a continued shortage of primary care physicians in the years to come. Even if this situation improves regarding numbers, a maldistribution of physicians, especially in rural or economically deprived parts of the country, will remain a problem. For years, the US military healthcare system has been involved in using alternative practitioner models to provide care for patients, especially those with chronic medical conditions such as systemic hypertension, diabetes mellitus, and hyperlipidemia. During my active duty years in the US military medical corps, I observed that one physician could successfully supervise 10 medics in providing excellent primary care of patients with specific conditions. As an outgrowth of the military experience using highly trained medics as primary care providers, the physician assistant and nurse practitioner professions were developed. Physician assistants and nurse practitioners working under the supervision of, or in collaboration with, physicians are now involved in the outpatient follow-up of patients,1 medication titrations and initiation, patient education, and consultations. In the inpatient setting, their duties include taking histories and performing physical examinations, making follow-up rounds, and helping to manage patients in the general wards and intensive care units. In this issue of The American Journal of Medicine, Zillich et al2 demonstrate the utility and effectiveness of using pharmacists in the long-term management of systemic hypertension, demonstrating their success in blood pressure control and treatment compliance in a veterans medical home model of primary care. Pharmacists met individually with patients, adjusted medications when necessary, and provided patient education. One might expect that pharmacists, with their knowledge of medications, would enhance patient treatment adherence and reduce the side effects of Funding: None. Conflict of Interest: None. Authorship: The author had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to William H. Frishman, MD, MACP, Department of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY 10595. E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.11.021
therapy. These professionals also may provide a more costeffective approach to blood pressure management. Schools of Pharmacy now require a Doctor of Pharmacy degree, with more rigorous training than in the past, including rotations in clinical pharmacy. Our own university has 2 schools of pharmacy. We have had clinical pharmacists round with us in the hospital and in our clinics, and their expertise has led to better drug selections, increased patient compliance, and a reduction in adverse reactions from therapy. Beyond the long-term treatment of hypertension as described by Zillich et al2 and others,3,4 one can envision pharmacists being involved in the long-term drug management of conditions such as hyperlipidemia, congestive heart failure, diabetes mellitus,5 and asthma.6 They could help in anticoagulation clinics,7,8 cigarette smoking cessation clinics, and immunization programs.9 Of course, the treatment protocols the pharmacists use need to be evidencebased, under the supervision of a physician. With better use of our allied health care professional groups, such as pharmacists, in a collaborative spirit that is patient centered, the national gap in primary care needs in the United States can be reduced considerably. At the same time, there should be greater patient drug adherence,10 fewer drugedrug interactions and drug side effects, and, ultimately, better clinical outcomes. However, this needs to be studied in clinical trials evaluating different primary treatment care models. William H. Frishman, MD Department of Medicine New York Medical College New York, NY Supplements Editor The American Journal of Medicine
References 1. Shaw RJ, McDuffle JR, Hendrix CC, et al. Effects of NurseManaged Protocols in the Outpatient Management of Adults with Chronic Conditions. Washington, DC: Department of Veterans Affairs; 2013. 2. Zillich AJ, Jaynes HA, Bex SD, et al. Evaluation of pharmacist care for hypertension in the Veterans Affairs patient centered home. Am J Med. 2015;128:539.e1-539.e6.
444 3. Hirsch JD, Steers N, Adler DS, et al. Primary care-based, pharmacistphysician collaborative medication-therapy management of hypertension: a randomized, pragmatic trial. Clin Ther. 2014;36:1244-1254. 4. Houle SK, Chatterley T, Tsuyuki RT. Multidisciplinary approaches to the management of high blood pressure. Curr Opin Cardiol. 2014;29: 344-353. 5. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:173-184. 6. Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic and economic outcomes of a community-based medication therapy management program for asthma. J Am Pharm Assoc. 2006;46: 133-147.
The American Journal of Medicine, Vol 128, No 5, May 2015 7. Chilipko AA, Norwood DK. Evaluating warfarin management by pharmacists in a community teaching hospital. Consult Pharm. 2014;29:95-103. 8. Maynard G, Humber D, Jenkins I. Multidisciplinary initiative to improve inpatient anticoagulation and management of venous thromboembolism. Am J Health Syst Pharm. 2014;71:305-310. 9. Bounthavong M, Christopher ML, Mendes MA, et al. Measuring patient satisfaction in the Pharmacy Specialty Immunization Clinic: a pharmacist-run immunization clinic at the Veterans Affairs San Diego Healthcare System. Intl J Pharm Pract. 2010;18:100-107. 10. Fischer MA, Choudhry NK, Bykov K, et al. Pharmacy-based interventions to reduce primary medication nonadherence to cardiovascular medications. Med Care. 2014;52:1050-1054.
