Community pharmacists could improve access to CV disease risk screenings

      Heart disease is the leading cause of death in the United States. It kills more than 600,000 people a year, accounting for one in four deaths. High cholesterol and hypertension are reliable indicators of heart disease risk. Relatively few American adults with these conditions have them under control.
      While lifestyle factors contribute in large part to the prevalence of hypertension and hyperlipidemia in the United States, barriers to care exacerbate the problem. Pharmacists, however, as two recent studies confirm, can improve access to routine screenings, improve quality of care, and thereby have a major impact on this public health epidemic. Though there are challenges to expanding pharmacists’ patient care services, given the opportunity, pharmacists could make significant contributions to preventive care using their clinical expertise and skills.
      “Pharmacists providing screenings can be a way to identify people early enough in the disease process that they don’t end up in an emergency situation, suddenly going from ‘Everything’s fine’ to ‘I’ve had a heart attack,’” said Meagan Rosenthal, PhD, assistant professor of pharmacy administration at the University of Mississippi. “Pharmacists can help prevent those situations.”

      New evidence

      Two recent studies demonstrate the impact pharmacists could have on heart disease prevention—if their scope of practice allowed it.
      At 184 pharmacies in Austria, pharmacists measured the body mass index, blood pressure, blood glucose, and total cholesterol of 6,800 patients. The mass screening uncovered a previously undiagnosed heart disease risk factor in 30% of the study participants, according to the October study in Open Heart.
      In Alberta, Canada, pharmacists have the authority to prescribe Schedule I drugs and blood products. In a study published in the September/October 2016 Canadian Pharmacists Journal, patients at 14 community pharmacies in Alberta participated in a randomized controlled trial that evaluated the benefits of pharmacist-prescribed cholesterol-lowering medications, along with other interventions.
      Pharmacists identified patients in their system who would be candidates for cholesterol screening. Ninety-nine patients with high cholesterol were randomized to the intervention or the control group. Those in the intervention group were prescribed medications as needed; appropriate lab tests were ordered; and patients received counseling on behavior changes, a copy of their laboratory results, and all necessary monitoring and in-person or telephone follow-up every 6 weeks. The control group received their test results, a pamphlet on heart disease, and usual care from a physician or pharmacist.
      At the end of the 6-week intervention period, 43% of those in the intervention group had achieved their cholesterol goal compared with 18% of those in the control group. Those in the intervention group were three times more likely to lower their cholesterol than the others.
      “One thing you can take from this research,” said Rosenthal, who coauthored the Canadian Pharmacists Journal study, “is that community pharmacists have the ability to contribute more to patient care than they do right now. They are an untapped resource and a gold mine for improving public health.”

      Case study

      Where sustainable payment mechanisms exist, pharmacy-based cardiovascular disease risk screenings are already helping patients. At Balls Food Stores, 28 grocery stores in the Kansas City metropolitan area offer free pharmacist-led biometric screenings for employees and spouses on the company health plan. Those who undergo the screening, and take advantage of any disease state management for which they are eligible, receive a discount on their insurance premiums and medication copayments.
      “The biggest advantage of the point-of-care screenings is getting people back into the health care system,” said Emily Prohaska, PharmD, BCACP, who is a clinical pharmacist at Balls Food Stores and an adjunct clinical assistant professor at University of Kansas School of Pharmacy. At the pharmacy, Prohaska encounters many company employees who were previously disengaged with the health care system. Without the low-barrier, easy-access screenings available at the pharmacy, these employees might live with high blood pressure or high cholesterol for indeterminate periods of time. Pharmacy screenings reveal to them the need to get follow-up care with a primary care provider.
      Prohaska recently met such an employee. His LDL cholesterol was more than 200, and he didn’t have a primary care physician. “He’d never been told that his cholesterol was high, but he was receptive to the information provided to him and understood that this was a serious risk.” Prohaska helped him find a primary care physician, and he agreed to schedule an appointment.
      The pharmacy offers disease state management programs for cardiovascular disease and diabetes that include monthly meetings with a pharmacist for the first 3 months and meetings every 6 to 12 weeks thereafter. In consultations of 30 minutes to 1 hour, patients learn the skills they need to manage and improve their condition.
      “We tailor the education and the skills to the gaps in their knowledge and teach them the skills they need to manage their conditions at a high performance level,” Prohaska said. “That’s the ideal progression through the program.”
      The program benefits the patients and their employer. More than one-half of the patients in the diabetes program have a glycosylated hemoglobin (A1C) goal of less than 7. The majority of patients reach their blood pressure and cholesterol goals. What’s more, health care expenditures for the company have been lower than projected every year since the program started.

      Ideal place to start

      Pharmacists have the skills and expertise to bring the kinds of benefits that Balls Food Stores offers its employees to patients at community pharmacies everywhere.
      “Pharmacists who are graduating today, in particular, have been rigorously trained for cardiovascular disease screening and management,” said Maria Thurston, PharmD, BCPS, who is a clinical assistant professor at Mercer University College of Pharmacy. “They are also trained extensively in communication abilities and providing counseling on lifestyle modifications like diet, exercise, and tobacco cessation.”
      Pharmacists offer the accessibility necessary to provide the between-visit follow-up care and monitoring that patients with high cholesterol, hypertension, or other risk factors for cardiovascular disease need. The Balls Food Stores program offers patients a quantity of face time with a provider that busy primary care practices can’t match.
      A recent study found that patients see their community pharmacist three times as often as their primary care provider. “That gives us lots of opportunities to engage with those patients,” Rosenthal said.
      Increased exposure enables pharmacists to build trusting relationships with their patients. This can lead to increased buy-in to the need for cholesterol-lowering medications, lifestyle change, and better adherence.
      Many pharmacists are trained and qualified to manage other diseases, too, but cardiovascular disease might be the ideal place to start. “Cardiovascular disease represents such a huge patient population,” said Thurston. “If you want to come up with a practical model that will work in your pharmacy, you can really drill down and develop a workflow model and provide some very specific training related to these types of screenings. And you’re probably going to get a whole lot of volume out of them.”

      Barriers and ways forward

      While pharmacists are qualified and well positioned to make an impact on the national burden of heart disease, a number of challenges lie in their way. The first challenge: “Who is going to pay?” Thurston asked. “Seeking provider status recognition is a very important part.”
      In the meantime, pharmacists might seek agreements with individual payers, such as self-insured employers or health plans, to reimburse for screenings offered to their beneficiaries.
      Without provider status or another reliable means of reimbursement, pharmacists will need to devise sustainable practice models and workflows that allow them to provide these services in a way that is beneficial, not detrimental, to the pharmacy’s revenue stream.
      “How do you develop a program that you can take to your manager that’s going to be sustainable and that’s not going to take time away from the things that, right now, pay for the pharmacy to be open?” said Rosenthal.
      Of note, the interventions in Open Heart and Canadian Pharmacists Journal saw relatively few patients over the course of the study. In Austria, each site saw 36 patients over 4 months. In Alberta, each site saw seven patients over 6 months. Given a legitimate reimbursement model, community pharmacies would need to see far more patients to justify the program. Therefore, workflow redesign or additional staff would be crucial.
      “There’s no way you can dispense medications at the same time that you’re sticking a needle in someone’s finger and checking a blood cholesterol,” said Thurston.
      In addition, to replicate a program like the one in Alberta, pharmacists would need prescribing authority through collaborative practice agreements. Some community pharmacists may feel they need additional training to perform the types of clinical services described in these studies. These pharmacists might seek continuing education or other training to prepare them to conduct biometric screenings.
      For community pharmacists who are interested in implementing screening programs for cardiovascular disease risk factors, the challenges are surmountable. “Whether you need to brush up on some training or figure out how to restructure the workflow,” Thurston said, “I encourage pharmacists, even if they are reluctant, to seize this opportunity because this is really where we can make an impact.”