Authors: Briana Bethune, Jamie Coates, Naomi Yates
Categories: Original Research, Hypertension, Delivery of Health Care, Pharmacists, Ambulatory Care, Antihypertensive Agents, Patient Care Team, Remote Consultation
Source: The Permanente Journal
Doi: 10.7812/TPP/25.100
Authors: Briana Bethune, Jamie Coates, Naomi Yates
Pharmacist intervention can improve blood pressure (BP) control during scheduled pharmacy appointments; however, remote pharmacist impact during in-person nurse visits remains unclear. This study evaluated whether real-time remote consultations with clinical pharmacy specialists (CPSs) during nurse visits improve BP outcomes for patients.
This retrospective cohort study included adult patients with hypertension and a repeat BP of 140–179/90–109 mmHg during a nurse visit from November 2023 to August 2024. Exclusion criteria included pregnancy, hospice/palliative care, and estimated glomerular filtration rate < 30 mL/min/1.73 m². The intervention group received immediate CPS consultation via secure chat; the control group received usual care from the “Doctor of the Day.” Outcomes included time to BP goal (≤ 140/90 mmHg), medication optimization, BP change from baseline, BP goal attainment, and enrollment in remote BP monitoring (RBPM).
Among 1726 patients (1466 control; 260 intervention), time to BP control was similar between groups (31.93 vs 31.21 days, respectively). The intervention group had significantly higher rates of medication optimization (35.5% vs 62.3%) and RBPM enrollment (6.6% vs 63.1%). BP goal attainment (87.1% vs 88.2%) and BP reductions were comparable between control and intervention groups (systolic: −23.06 vs −24.91 mmHg; −9.76 vs −8.27 mmHg, respectively).
The integration of remote CPS consultation into nurse visit appointments demonstrated higher rates of medication optimization and RBPM enrollment while providing similar BP control outcomes as compared to usual care.
The remote pharmacy hypertension consult service demonstrated a substantial impact by transforming ambulatory care practice and expanding access to care through use of remote technology.
Hypertension is one of the most prevalent chronic conditions worldwide and a leading modifiable risk factor for cardiovascular morbidity and mortality. Nearly half of adults in the United States are diagnosed with hypertension, yet only 22.5% of these individuals achieve adequate blood pressure (BP) control. ^1^ Poorly controlled hypertension significantly increases the likelihood of heart attack, stroke, kidney disease, and other life-threatening complications, underscoring the urgent need for effective interventions to improve BP management. ^2–4^
In the United States, BP has historically been managed via scheduled visits with primary care practitioners in office. Health care practitioners optimize medications based on home and in-office BP readings, comorbidities, and medication history. ^5^ As demonstrated by Dr Bartolome, et al, achieving BP control often requires a multifaceted, team-based approach, combining pharmacologic therapy with nonpharmacologic strategies such as dietary changes, weight loss, and increased physical activity. ^6^ However, real-world barriers (including limited access to health care practitioners, inconsistent follow-up, and inadequate medication optimization) continue to hinder progress toward BP goals for many patients. To address these challenges, pharmacist-led interventions have emerged as an effective strategy to enhance hypertension management. ^7,8^
Pharmacists are uniquely positioned to contribute to hypertension management due to their expertise in medication therapy optimization and patient-centered care. Evidence from previous studies has demonstrated that pharmacist-led interventions, including scheduled consultations and collaborative care models, significantly improve BP control rates. ^7,8^ These interventions often address critical barriers to effective hypertension management, including poor medication adherence, lack of therapeutic adjustments, and inadequate patient education. Many of these studies have focused on structured appointments, leaving a gap in understanding the potential impact of pharmacists in more dynamic, on-demand clinical settings.
Nurse visits, often characterized by rapid patient turnover and immediate clinical needs, provide a critical opportunity for intervention, particularly for patients with elevated BP readings. Patients identified with elevated BP readings after repeat check during nurse visits receive preliminary counseling and are referred for further evaluation or intervention by a primary care practitioner or specialist. This approach often leads to delays in care and interruption to physician schedules.
Despite the potential benefits of remote pharmacist interventions, there is limited evidence evaluating the use of a remote pharmacist to provide real-time medication recommendations during an in-person visit with another clinician. Dr Bartolome’s study showed a team-based approach was successful for hypertension management, where pharmacists were physically present during patient visits. ^6^ This study was designed to evaluate the impact of a remote pharmacy hypertension consult service, “On the Spot” (OTS), on time to BP control, achievement of BP goals, and related outcomes such as medication optimization and utilization of remote BP monitoring (RBPM). The authors hypothesized that OTS would have a positive impact on hypertension outcomes. This could have important implications for integrating remote pharmacy services into routine clinical practice and improving the quality of hypertension management within integrated health care delivery systems.
Kaiser Permanente Georgia is an integrated health care delivery system, serving approximately 330,000 patients statewide. Patients receive coordinated care from physicians, nurses, and pharmacists in a variety of specialties including, but not limited to diabetes, heart failure, chronic kidney disease, and hypertension. This study focused on evaluating the newly developed OTS remote pharmacy hypertension consult service.
OTS was developed as a collaborative effort between nursing and clinical pharmacy. It was designed to enable nurses to connect with clinical pharmacy specialists (CPSs) remotely, providing immediate consultations and optimizing antihypertensive therapy when needed. The consult service began as a limited launch at just one Kaiser Permanente Georgia facility at the end of November 2023 before slowly expanding to all Kaiser Permanente Georgia facilities by November 2024 as resources and appropriate training allowed. By facilitating timely medication adjustments and enrolling eligible patients in RBPM, this model was designed to improve outcomes for patients with uncontrolled hypertension.
Patients with elevated BP upon repeat check at a nurse visit are eligible for a consult. Nurses trained for OTS consult clinical pharmacy through the OTS (intervention) process, unless the patient has concerning symptoms and/or BP ≥ 180/110 upon repeat check; then, they consult “Doctor of the Day” (DOD) (control). Nurses at facilities not yet trained for OTS utilization would provide usual care and consult the DOD (control) in person for all patients with elevated BP. The DOD provides recommendation(s) as their schedule permits, in addition to their daily patient load. The DOD commonly recommends that patients follow up with their primary care practitioner or return for a follow-up nurse visit prior to medication optimization. For patients in the intervention group, the nurse sends a secure chat to the remote pharmacist on call, who optimizes medications and orders laboratory tests as needed following a brief chart review. Recommendations and documentation from the remote pharmacist on call are often provided/completed within 5–15 minutes from initial nurse consultation. All orders (medication and laboratory) are placed by the pharmacist via collaborative practice agreement. The nurse communicates the recommendation(s) to the patient and assesses whether the patient meets the enrollment requirements for the RBPM program. Requirements for remote monitoring include arm size ≤ 20 inches, smartphone access, and motivation to adhere to monitoring frequency. Patients who qualify and are agreeable to remote monitoring are transitioned to the pharmacy hypertension service for pharmacist follow-up via telephone. The service utilizes readings uploaded by the patient via the BP monitor to further optimize patients’ BP medication regimen and gain BP control. Patients who do not qualify for this remote pharmacy hypertension service are scheduled for a follow-up nurse or physician appointment.
The potential benefits of OTS are multifaceted. By providing immediate access to pharmacist expertise, OTS may reduce the time required to achieve BP control, improve the percentage of patients reaching their target BP goals, and enhance medication optimization. Additionally, incorporating RBPM can facilitate ongoing patient engagement and adherence to treatment plans, further supporting long-term hypertension control. Finally, leveraging remote CPSs can optimize interdisciplinary workflows by reducing the workload on nurses and physicians, allowing them to focus on other tasks aligned with their scope of practice.
This study was exempt from institutional review board approval due to its quality improvement nature. The study utilized an observational, retrospective cohort design to evaluate the impact of a remote pharmacy hypertension consult service compared to usual care. An administrative database was used to identify patients meeting criteria. Assessments were based on a 4-month follow-up period.
The study included adult patients diagnosed with hypertension who had BP between 140–179/90–109 mmHg upon repeat check during nurse visits from November 2023 to August 2024, where Kaiser Permanente Georgia’s OTS remote pharmacy hypertension consult service or DOD was utilized. Patients who were pregnant, enrolled in hospice/palliative care, or had an estimated glomerular filtration rate < 30 mL/min/1.73 m^2^ were excluded from the study, as they did not qualify for OTS. Of note, all patients included in the study were eligible for either program.
The primary outcome of this study was to assess time to BP goal (defined as ≤ 140/90 mmHg according to the American Academy of Family Physicians 2022 guidelines) for patients managed by OTS compared to patients who received usual care. The secondary objectives were to evaluate medication optimization (defined as medication adjustments with the goal of improving outcomes), change in BP from baseline, and the percentage of patients who achieved BP goal compared to usual care. The tertiary objective was to compare the percentage of patients enrolled in RBPM where OTS was utilized vs usual care.
All patients meeting inclusion criteria were included in this study. Data were obtained from patient electronic medical records. Descriptive statistics were used to report patient characteristics and to evaluate the impact of the remote pharmacy hypertension consult service compared to usual care. Means and standard deviations were calculated for continuous variables, and t tests were used to determine their statistical significance. Percentages were reported for categorical data and nominal data, and χ^2^ tests were used to determine their statistical significance. An alpha value of less than 0.05 was considered significant for all analyses.
The study included 1726 patients, with 1466 patients in the control group receiving usual care through DOD and 260 patients in the intervention group managed by the OTS remote pharmacy consult service. Baseline characteristics between groups were similar in terms of age, gender, body mass index, estimated glomerular filtration rate, and comorbid conditions. Of note, there were statistically significant differences in race distribution between groups (P = .002). The majority of patients in both groups identified as Black (Table 1).
The primary outcome of average time to achieve BP control was 31.93 days in the group of patients using DOD and 31.21 days in the group of patients using OTS, showing no statistically significant difference (P = .72). Secondary outcomes revealed that medication optimization was significantly higher in the group of patients using OTS, with 62.3% of patients receiving an antihypertensive order at the nurse visit compared to only 35.5% in the group of patients using DOD (P < .0001). There was no statistically significant difference in the percentage of patients who achieved BP control < 140/90 mmHg between groups (87.1% [DOD] vs 88.2% [OTS]; P = .51). The reduction in systolic and diastolic BP from baseline was comparable between groups, with no statistically significant differences observed (systolic: −23.06 [DOD] vs −24.91 mmHg [OTS], P = .13; −9.76 [DOD] vs −8.27 mmHg [OTS], P = .09). Tertiary outcomes showed a significant contrast in the utilization of RBPM. Enrollment in RBPM was significantly higher in the group of patients using OTS (63.1%) compared to the group of patients using DOD (6.6%) (P < .0001), demonstrating the impact of pharmacist engagement on expanding access to remote monitoring. All study outcomes data can be found in Table 2.
This study evaluated the implementation of a novel, remote pharmacy hypertension consult service within Kaiser Permanente Georgia, an integrated health care system. OTS provided similar BP control outcomes compared to DOD while significantly increasing medication optimization and RBPM enrollment, improving access to pharmacist-led interventions. The marked increase in medication optimization observed in the group of patients using OTS suggested that pharmacists provided meaningful, actionable recommendations at the point of care. Additionally, enhanced RBPM enrollment highlighted the service’s potential to promote continuous patient engagement and long-term monitoring via the pharmacy hypertension service. Increased utilization of these pharmacy services allows for a substantial portion of hypertension management responsibilities to be transferred from nurses and physicians, enabling them to focus on other clinical priorities and patients. These findings align with prior evidence, including the work of Dr Bartolome, supporting the role of pharmacists in chronic disease management. However, this study’s use of a remote pharmacist to provide real-time medication titration and patient enrollment in RBPM offers a unique approach to team-based care.
This study had many strengths, including the setting within an integrated health care delivery system, which allowed for a larger, more diverse patient population and streamlined data collection. In addition, this study was generalizable, as the population studied was consistent with current racial disparities of hypertension in the United States, with Black patients having the highest prevalence followed by White, Asian and Asian American, and Hispanic patients. ^9^ This was a novel method of utilizing remote clinical pharmacists in direct patient care encounters, although slow rollout of the newly developed OTS service contributed to a smaller sample size for the intervention group. In addition to a smaller intervention sample size, another limitation of the study was the relatively short follow-up period where the number of patient visits was not captured, making it unclear how many care touchpoints occurred in each group.
Despite the limitations, this study demonstrated the feasibility and value of remote pharmacist-led intervention aimed at optimizing hypertension care. The ability to engage CPSs remotely during in-person nurse visits represents a unique opportunity to utilize pharmacist expertise without requiring on-site pharmacist presence. Future work should focus on evaluating long-term outcomes, impact on medication adherence, and the integration of the OTS model into standardized clinical workflows.
The OTS remote pharmacy hypertension consult service demonstrated a substantial impact on process measures, including higher rates of medication optimization and enrollment in RBPM compared to usual care. The higher medication intervention and RBPM enrollment rates paired with similar BP control outcomes suggested that integrating remote pharmacist consults into nurse visits enhances hypertension management. Benefits may include reducing delays in care, clearing physician and nurse schedules, and increasing rate of follow-up. These findings highlighted the value of immediate remote pharmacist intervention and underscored the potential for integrated remote pharmacy services to enhance hypertension management in health care systems.