Original Research
Physician-pharmacist collaborative care in dyslipidemia management: The perception of clinicians and patients

https://doi.org/10.1016/j.sapharm.2010.05.003Get rights and content

Abstract

Background

Collaborative practices allow physicians and pharmacists to comanage pharmacotherapy to maximize the benefits of medication regimens. The Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia (TEAM) study compared the efficacy of a physician-pharmacist collaborative primary care (PPCC) intervention, where pharmacists requested laboratory tests and adjusted medication dosage, to the usual care (UC) for patients under treatment with lipid-lowering medication.

Objective

In a qualitative study nested within the TEAM study, the perceptions of physicians, pharmacists, and patients regarding the PPCC model, interprofessional collaboration, and the clinicians' willingness to implement the model in their practice were explored.

Methods

In the area of Montreal (Quebec, Canada), TEAM study participants assigned to the PPCC group were invited to participate. Individual semistructured interviews with physicians (n = 7) and 2 six-member focus groups with pharmacists (n = 12) and patients (n = 12) were analyzed using a phenomenological approach.

Results

The vast majority of participants reported PPCC was more structured and systematic than the UC they had received previously, wherein physicians prescribe and adjust pharmacotherapy and pharmacists provide the counseling and dispense medications. Many patients felt they received better follow-up and reported being reassured and well informed, making them more inclined to care for themselves better. These feelings were attributed largely to the pharmacists' accessibility and ability to communicate with them easily. Given the physician shortage, physicians perceived interprofessional collaboration as almost inevitable. They considered PPCC to be safe and effective. However, obstacles were also identified. Physicians were concerned that it might alter their special relationship with patients and threaten their overall medical follow-up. Pharmacists felt enthusiastic about their new role, but found PPCC time consuming and thought it might not be applicable to all the patients.

Conclusions

PPCC model was highly appreciated by patients, and clinicians saw it as beneficial to patients. However, several obstacles still have to be overcome before the model can be implemented in the current health care context.

Introduction

Dyslipidemia is often not optimally managed. Adherence to and persistence with lipid-lowering medication are low,1, 2 and a large proportion of patients remain on their initial dose and do not achieve recommended target lipid levels.3, 4

When community pharmacists provide patient counseling on medication and lifestyle5, 6, 7, 8, 9, 10, 11 and make recommendations to physicians regarding pharmacotherapy,6, 9, 12, 13, 14 dyslipidemia control and adherence to treatment are enhanced. Worldwide, the role of community pharmacists is expanding.15 In Great Britain, since 2006 pharmacists with specific training are allowed to act as independent prescribers for any clinical condition within their clinical competence. Simvastatin ranks among the top 5 drugs prescribed by British pharmacists.16 In Quebec (Canada), pharmacists can now initiate and adjust drug therapy in accordance with a physician's prescription and request laboratory analyses when needed.17 This is similar to the American Collaborative Drug Therapy Management initiative, wherein pharmacists manage and modify drug therapy according to written protocols between pharmacists and physicians. Over 40 US states have collaborative practice laws.18

These new legislations increase the potential for comanagement of pharmacotherapy by physicians and pharmacists. This entails the coordination and harmonization of the care delivered by the various health professionals, the sharing of patient's medical information and effective communication between professionals. In Quebec, collaborative practice has not yet been widely applied in primary care. At this point in time, it is therefore relevant to learn about the experience of clinicians and patients who have tried this new primary care practice model.

The TEAM study19, 20 (Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia) compared the efficacy of a physician-pharmacist collaborative primary care (PPCC) intervention with the usual care (UC) for dyslipidemia patients. Clusters of primary care physicians and community pharmacists were recruited and randomized to the PPCC or the UC group. PPCC pharmacists participated in a 1-day workshop to prepare them to apply the intervention.21 Physicians were responsible for making the diagnosis and for prescribing lifestyle changes and statin treatment. Pharmacists then monitored lifestyle changes, tolerance, efficacy, and adherence to pharmacotherapy; they were responsible for requesting laboratory analyses and adjusting statin dosage accordingly. PPCC intervention ended when target lipid levels were reached for at least 3 months. The duration of the pharmacist follow-up varied from patient to patient and ranged from 5 to 12 months. After each visit, the pharmacist faxed the physician a report form summarizing the intervention. In the UC arm, the physicians adjusted lipid-lowering pharmacotherapy and pharmacists provided the usual counseling and dispensed medications. When compared with the UC, PPCC patients had more health professional visits and laboratory tests, were more likely to have their lipid-lowering treatment changed, and more likely to report lifestyle changes. However, after 1 year, this did not translate into clinically significant between-group differences in lipid control.20 Substantial reduction in low-density lipoprotein-cholesterol were observed in both study groups (PPCC: −1.1 mmol/L [95% confidence interval (CI): −1.3 to −1.0]; UC: −0.9 mmol/L [95% CI: −1.0 to −0.8]) with high proportions of patients reaching their target lipid levels (PPCC: 80.6%; UC: 73.5%; adjusted relative risk: 1.16 [95% CI: 1.01 to 1.32]).

A qualitative study nested within the TEAM study was conducted to explore the perceptions of clinicians and patients regarding the physician-pharmacist collaborative care (PPCC) model used in the TEAM study, interprofessional collaboration, and the clinicians' willingness to implement the model in their practice.

Section snippets

Study design

After the completion of the TEAM study, participants assigned to the PPCC intervention were invited to participate in a phenomenological qualitative study.22, 23 Experiential data are thus preferred because “they provide the most complete information pertaining to the specific meanings of objects.”24 Approval was given by the ethics committee of the Centre de santé et de services sociaux de Laval.

Participants

Within the TEAM study, 8 PPCC clusters, all located in the area of Montreal (Quebec, Canada),

Results

Most of the physicians were male, had graduated more than 15 years earlier, and practiced in a conventional clinic. Pharmacists were mostly female, half had been practicing for more than 15 years, and the majority owned a pharmacy located in a medical clinic. Most patients were men at high risk of coronary heart disease and had reached their target lipid level at the end of the pharmacist's follow-up (Table 1).

Summary of main findings

This qualitative study explored the perception of family physicians, community pharmacists, and patients who were involved for the first time in a PPCC model for the management of dyslipidemia, where community pharmacists were responsible for adjusting statin treatment. Clinicians and patients highly appreciated the intervention. Compared with the traditional approach, wherein physicians prescribe and adjust pharmacotherapy and pharmacists provide counseling and dispense medication, it was

Acknowledgments

The authors thank Josée Robillard and Nathalie Caron for their invaluable contribution to this project. They also thank all the physicians, pharmacists, and patients involved in this study and Chantal Legris for her assistance in the preparation of this article. Research scholars Lyne Lalonde, Lucie Blais, and Sylvie Perreault receive financial support from the Fonds de la recherche en santé du Québec.

The TEAM study was made possible by research grant from the Canadian Institutes of Health

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  • Cited by (0)

    Prior presentations: An abstract of this article was presented to the Association francophone pour le savoir on May 5, 2008, Quebec, Canada; the 96th Annual National Conference of the Canadian Pharmacists Association on June 1, 2008, Victoria, Canada; the IXth World Conference on Clinical Pharmacology and Therapeutics on July 27, 2008, Quebec, Canada; and the 36th North American Primary Care Research Group Annual Meeting on November 18, 2008, Rio Grande, Puerto Rico.

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