Blood Pressure
Interventions led by pharmacists and community health workers are most likely to help patients with hypertension achieve disease control, according to research published July 19, 2024, in the American Heart Association’s (AHA’s) journal Circulation: Cardiovascular Quality and Outcomes.
Using random effects models and generalized estimating equations, investigators found that the biggest reductions in systolic BP and diastolic BP occurred under the direction of pharmacists, followed by community health workers. With a pharmacist guiding them, participants in the meta-analysis of 100 randomized controlled trials saw their systolic BP number fall by as much as 7.3 points and their diastolic reading drop by 3.9 points.
Lead study author Katherine Mills, PhD, said that while all health care professionals have success in reducing BP—and significant reductions in BP were observed in the study for all health care professional categories—pharmacists and community health workers, who are outside of a typical primary care encounter, appear to most effectively reduce BP.
“Blood pressure control often requires multiple visits for medication titration and adjustment, tasks that pharmacists can do well,” said Mills, who is an associate professor at Tulane University School of Public Health and Tropical Medicine.
After adjusting for type of intervention, she noted that pharmacists were still very effective at BP reduction.
“That suggests that they are very good at delivering all types of interventions, not just those where they can titrate medications, but also those where they are doing education and other tasks,” Mills said.
The differences in BP reduction were not statistically different between pharmacists and community health workers.
Researchers focused on randomized controlled trials of different interventions meant to address barriers to BP control, stratified according to what category of health care professional delivered the care. They also saw greater BP reductions from community pharmacists than from pharmacists working in clinics and hospitals but stated more analysis is needed.
“The findings of this meta-analysis about the effectiveness of both pharmacists and [community health workers] is hardly surprising and backup other systematic reviews examining the effectiveness of pharmacists and [community health workers] in improving blood pressure control,” said Richard Segal, RPh, PhD, from UF College of Pharmacy, who was not part of the study but has done research on pharmacists and community health workers working in tandem.
Pharmacists’ strengths
“Where blood pressure reductions can be achieved through a variety of health care professionals’ intervention, pharmacists were identified as the ones who were best able to optimize results most effectively,” said Christopher Daly, PharmD, from the University at Buffalo School of Pharmacy and Pharmaceutical Sciences, who was not involved with the study. “Pharmacists are highly trained in medication optimization strategies along with patient engagement opportunities.”
The analysis allowed for direct head-to-head comparison among different health care professionals. And in pairwise comparisons, pharmacists were much more effective than physicians, nurses, and other health care professionals in providing BP interventions.
Mills said there are several reasons why pharmacists and community health workers could help patients reduce their BP.
“Medication side effects are an important reason for nonadherence to medications in hypertension patients,” said Mills. “Pharmacists are very good at educating patients about side effects due to their training and experience.”
Another reason could be due to what pharmacists are capable of in a different practice setting. Primary care providers’ schedules only allow for short patient visits, even though many patients have multiple comorbidities that need to be addressed.
“This leaves little time for BP medication titration and health education around medication adherence and lifestyle modifications that can impact BP,” said Mills. “Therefore, task sharing between primary care providers and pharmacists who may have more time for tasks that control BP like medication titration and health coaching could be an effective approach for BP control.”
Enter community health workers
Mills said community health workers may not have the training pharmacists do, but they have the advantage of being from the same communities as their patients and relating to them in a way other health care professionals may not. Community health workers are members of communities who work in association with their local health care system to provide culturally responsive care to patients.
Authors of the study also mentioned that community health workers can be a “cost-efficient alternative to interventions delivered by pharmacists, physicians, and other highly specialized occupations and could lead to better intervention sustainability because they are embedded in the communities they serve.”
“Because [community health workers] usually share ethnicity, language, socioeconomic status, and life experiences with their patients, they can play an important role in helping patients, such as those with high blood pressure, overcome barriers to medication use and more generally access problems to health care by providing social support by talking with them and motivating them by using culturally appropriate strategies,” said Segal.
Pharmacists and community health workers team up
Segal said one of the main takeaways from the study should be the powerful partnership pharmacists and community health workers can have on patient outcomes.
“On their own, both pharmacists and [community health workers] can improve BP control,” said Segal. “But we think it’s time to supercharge the effectiveness of the pharmacist through partnering with [community health workers]. The shared life experiences between [community health workers] and patients have the promise to lead [community health workers] to uncover medication use practices that pharmacists are not able to discover on their own because the relationship with their patients is often not authentic, which, for many minority patients, can only be established through shared experiences.”
Tripp Logan, PharmD, from L&S Pharmacy and Medical Arts Pharmacies in Charleston, MO, has put this concept into practice. Working with Missouri’s department of health as well as other state entities, Logan said they were the first pharmacy in Missouri to train community health workers. Funded through a state grant, they have had community health workers complete a training program specific to pharmacy.
He said the community health worker leverages local relationship-based care coordination and care gap closures, while the pharmacist supports local relationship-based medication optimization, clinical care gap closures, and positive clinical outcomes.
“The combo is proving out to be an amazing value driver,” said Logan. He said it has produced “a 1 + 1 = 10 outcome” in both practice and within their research.
Much of the research Segal has conducted supports partnerships between pharmacists and community health workers. For instance, a study from Segal and colleagues published in 2020 in JAPhA found that this collaboration was highly effective in resolving medication adherence barriers faced by American Indian and Black patients with hypertension and in reducing BP. ■