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Pharmacist Management of Hypertension: An Examination of Clinical and Economic Outcomes and Remuneration for Expanded Services Open Access


Other title
Pharmacy practice
Health economics
Type of item
Degree grantor
University of Alberta
Author or creator
Houle, Sherilyn
Supervisor and department
Tsuyuki, Ross (Medicine)
Examining committee member and department
Chuck, Anderson (Public Health Sciences)
McAlister, Finlay (Medicine)
Department of Medicine
Experimental Medicine
Date accepted
Graduation date
Doctor of Philosophy
Degree level
Background: One-third of Canadian adults with hypertension remain uncontrolled. As drug therapy experts, pharmacists can play a role in addressing this challenge, particularly when utilizing prescribing authorization in Alberta. However, the clinical effectiveness of pharmacist management of hypertension, particularly prescribing, has not yet been established, and remuneration strategies for these services need to be determined. Methods: This thesis consists of five studies. The first estimates the cost-saving potential of pharmacist care for hypertension resulting from reduced cardiovascular events. The second study reports on the current worldwide remuneration landscape for pharmacists’ clinical care services, including eligible services, fees, and data on uptake and outcomes. Then, we examine the business implications of performing case finding and medication management activities in community pharmacy, to quantify the potential magnitude of revenue that these services can generate. The fourth study delves into the clinical effectiveness of pay-for-performance (P4P) versus other pay strategies, to determine if this novel approach results in improved quality of care as hypothesized. Finally, we report on the results of a randomized controlled trial of pharmacist prescribing for patients with uncontrolled hypertension, specifically comparing outcomes achieved when pharmacists were paid by P4P versus flat fees. Results: A pharmacist prescribing intervention lowered systolic BP by 7.0 (SE 2.5) mmHg versus usual care. Since cost-savings has been established following BP lowering of 5.6 mmHg, the added benefit from pharmacist prescribing is likely both clinically- and cost-effective. However, BP lowering achieved under P4P was not significantly different than observed under fee-for-service, although this study was under-powered. This is consistent with research among P4P physicians, where uncontrolled studies suggested benefit, but subsequently not substantiated by controlled trials. Pharmacists are increasingly being paid for clinical care services worldwide, and all programs follow the fee-for-service model. Outcomes of pharmacist remuneration suggest that uptake is suboptimal, despite evidence of patient benefit and cost-effectiveness. Conclusion: Pharmacist prescribing offers significant blood pressure lowering benefit, and a gain over recommendation-based intervention. To ensure uptake and sustainability, remuneration needs to consider the changing pharmacy business model. P4P is unlikely to result in improved care quality and is therefore not recommended at this time.
Permission is hereby granted to the University of Alberta Libraries to reproduce single copies of this thesis and to lend or sell such copies for private, scholarly or scientific research purposes only. Where the thesis is converted to, or otherwise made available in digital form, the University of Alberta will advise potential users of the thesis of these terms. The author reserves all other publication and other rights in association with the copyright in the thesis and, except as herein before provided, neither the thesis nor any substantial portion thereof may be printed or otherwise reproduced in any material form whatsoever without the author's prior written permission.
Citation for previous publication
Houle SKD, Chuck AW, McAlister FA, Tsuyuki RT. Effect of a pharmacist-managed hypertension program on health system costs: an evaluation of the Study of Cardiovascular Risk Intervention by Pharmacists-Hypertension (SCRIP-HTN). Pharmacotherapy 2012;32(6):527-37.Houle SKD, Chuck AW, Tsuyuki RT. Blood pressure kiosks for medication therapy management programs: Business opportunity for pharmacists. J Am Pharm Assoc 2012;52(2):188-94.Houle SKD, McAlister FA, Jackevicius CA, Chuck AW, Tsuyuki RT. Does Performance-Based Remuneration for Individual Health Care Practitioners Impact Patient Care? A Systematic Review. Ann Intern Med 2012;157:889-99.

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