Published On December 20, 2018
ABOUT A QUARTER OF HEART ATTACKS STRIKE PEOPLE who have already had one. Nearly all of those patients have prescriptions for medications that can reduce their risk, but many patients don’t take those drugs. A study looking at one of the more common and well-tolerated drugs, angiotensin-converting enzyme (ACE) inhibitors, found that 7% of patients stopped taking them within a month and half no longer used the drugs by the two-year mark.
Some patients may not fill their prescriptions because they can’t afford them, while others simply opt out. Many patients, however, may experience side effects and need to have their dosage adjusted—a fussy process that a busy specialist might find hard to manage. Enter the prescribing pharmacist.
These days, a growing number of pharmacists can prescribe medications, conduct health screenings and give vaccinations. It would make sense to also allow them to help manage patients’ care outside a hospital or doctor’s office. Calum MacRae, vice chair for Scientific Innovation in the Department of Medicine at Brigham and Women’s Hospital in Boston, helped start a program in which pharmacists team up with “health coaches” to assist patients with heart disease.
Q: What patients were you trying to reach with this program?
A: We focused on those who’d had a heart attack or stroke and who weren’t meeting their targets in maintaining healthy lipid levels or blood pressure. As we managed to keep them on the right dose of their medications, 92% of patients reached their goal within 12 weeks. Staying on treatment turned out to be a powerful way to drive costs down and improve care.
Q: What does this program do to encourage compliance?
A: Instead of going to the doctor when a dosage needs adjustment, patients take tests that can be done at home or in a lab. They report these results to a health coach, a junior member of the clinical team who checks in with them regularly. The health coach then enters the results into an informatics system, whose algorithms provide step-by-step guidelines on what to do next—additional lab tests, for example, or a new prescription. The pharmacist reviews the prescription recommendations and oversees the whole process.
For the first draft of these guidelines, we used results from large-scale randomized trials and consensus best practices. But as more and more patients use the program, their data is collected and fed into an artificial intelligence “engine,” helping it learn what works and what doesn’t.
Q: Why do pharmacists, rather than doctors, serve as your team leaders?
A: We thought that approach might help patients improve more quickly. Normally, patients try a first dose of a medication, then see a doctor a few weeks later to see how it’s working and whether it needs to be changed. But suppose that first appointment gets cancelled? Suddenly it’s three months later and patients may not quite be at their goal even a year after a drug was first prescribed.
Enabling pharmacists to run a larger part of chronic disease management frees up physicians to focus on less routine tasks. Doctors get involved only when the algorithm says they need to be.
Q: How has this approach worked so far?
A: In addition to helping patients reach their health goals, the program has reduced costs for patients by 60% and adverse events have also been reduced.
Q: Could pharmacist-led teams have a similar impact helping manage other conditions?
A: We think they can. We wanted to start with something relatively simple and well understood. But we’re now building other programs and decision models for a series of chronic diseases, starting with heart failure and diabetes.
We have about 1,000 patients in a pilot program for heart failure, in which the goal is to get them on the best doses of all the different types of drugs needed for the condition. Heart failure is more complicated than treating people who have had a heart attack, because heart failure patients are sicker and their condition changes more rapidly. The kind of system we piloted with the earlier program works best for conditions that have robust evidence. That gives you confidence in the model that is guiding the pharmacists and health coaches. But even where there isn’t a lot of evidence about treatment, it’s possible to build consensus slowly and carefully using real-world data and artificial intelligence.
Q: Are there other advantages to this model of care?
A: It could also reduce the cost of clinical trials, because we can enlist pharmacists and their teams to manage medications we want to test and have them collect accurate data. And they can do this out in the real world, without patients being forced to go to a clinical trial location. Some cardiology trials cost as much as $800 million—our program should let us perform a trial for a tenth of the cost.
Q: Are there plans to expand the program to other places?
A: We are collaborating with pharmacists and patients across Partners HealthCare and are working with teams in the United Kingdom, continental Europe and Australia. We are also doing a test with the College of Pharmacy at the University of Utah to work with community pharmacists in managing care for patients in remote parts of the state.
This approach reimagines the pharmacist’s role to go beyond just prescribing and providing information about drugs. The potential collaborations are promising.
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