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

  • Author / Creator
    Houle, Sherilyn
  • 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.

  • Subjects / Keywords
  • Graduation date
    Spring 2014
  • Type of Item
  • Degree
    Doctor of Philosophy
  • DOI
  • License
    This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for non-commercial purposes. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.
  • Language
  • Institution
    University of Alberta
  • Degree level
  • Department
  • Specialization
    • Experimental Medicine
  • Supervisor / co-supervisor and their department(s)
  • Examining committee members and their departments
    • Chuck, Anderson (Public Health Sciences)
    • McAlister, Finlay (Medicine)