skyblue

作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　November 23, 2009 — 根據發表於11月23日內科醫學誌的前瞻性群聚隨機控制試驗結果，相較於只有醫師照護的病患，由醫師和藥師團隊照顧的高血壓病患，可以有較低的血壓值且比較可能達到血壓控制目標。
　　
　　愛荷華大學、愛荷華市退伍軍人管理中心的Barry L. Carter博士等人寫道，研究顯示，當臨床藥師參與病患處置時，可以改善血壓控制。研究目標是，評估社區基礎醫療機構中，醫師和藥師合作的模式是否可以改善血壓控制。
　　
　　這項研究中，有402名血壓控制不佳的病患(平均年紀為58.3歲)，來自6個診所，研究者隨機指定其中3個診所為控制組，另外3個診所為介入組，由醫師和藥師進行團隊照護。介入組中，臨床藥師根據全國指引提供藥物治療建議給醫師，由研究護士進行血壓測量和24小時的血壓監測。
　　
　　控制組中，平均指引順從度分數從開始時的49.4 ± 19.3，增加到6個月時的53.4 ± 18.1(增加8.1%)，介入組則是增加了55.4% (從開始時的40.4 ± 22.6，增加到6個月時的62.8 ± 13.5；校正組間比的P值 = .09 )。
　　
　　控制組血壓平均減少6.8/4.5 mm Hg，介入組為20.7/9.7 mm Hg (校正組間收縮壓比的P值< .05)。
　　
　　血壓校正差異值，收縮壓為 -12.0 mm Hg (95%信心區間[CI]為 -24.0 至0.0)，舒張壓為 -1.8 mm Hg (95% CI，-11.9至8.3)。24小時血壓值的效果程度相似。控制組中，29.9% 的病患達到血壓控制，介入組為63.9% (校正勝算比為3.2；95% CI為2.0 – 5.1；P < .001)。
　　
　　研究作者寫道，醫師和藥師合作介入可以達到較佳的平均血壓和整體血壓控制率；需要進行額外研究，以評估植入團隊基礎慢性疾病照護的策略。
　　
　　研究限制包括，診所數少，控制組可能有一些難以達到改善血壓的因素，退出率高於之前的效果性研究，無法一般化到社區基礎的家庭醫學診所之外；此外，無法一般化到未警覺自己有高血壓的病患。
　　
　　作者們結論表示，此研究的結果認為，有臨床藥師的診所或醫療體系應考慮重新分配其職務，以提供更直接的病患照護，進而明顯改善血壓控制。此模式的後續研究應包括更多地區的更多診所、更多種族和社會經濟分布，因為這些人對於此一介入方式可能有不同反應。
　　
　　編輯評論中，加州大學舊金山分校的Helene Levens Lipton博士表示，就這篇和其他兩篇研究，團隊基礎的介入可促進照護品質且改善臨床結果，不過，在醫療服務使用和費用方面有些差異。
　　
　　Lipton博士寫道，一旦全國再度進行健康改革的討論時，品質議題和費用抑制一定會在議程中。表述這些挑戰的方法之一，就是包括醫師和其他健康專業一起合作的團隊基礎健康照護服務。醫療之家—強調以初級照護為中心，全面提供健康照護和給付改革的一種模式— 提供運用團隊基礎照護的機會，可全面而嚴謹的評估品質和費用的影響。
　　
　　國家心臟、肺臟和血液研究中心的資金支持本研究。健康照護與研究局、治療教育和研究品質中心、退伍軍人健康管理局支持部份作者。
　　
　　Levens Lipton博士宣告沒有相關財務關係。


Team-Based Care With a Pharmacist Linked to Better Blood Pressure Control

By Laurie Barclay, MD
Medscape Medical News

November 23, 2009 — Patients in whom hypertension is managed by a physician–pharmacist team have lower blood pressure (BP) levels and are more likely to reach goals for BP control than those treated by a physician alone, according to the results of a prospective, cluster randomized controlled clinical trial reported in the November 23 issue of the Archives of Internal Medicine.

"Studies have demonstrated that [BP] control can be improved when clinical pharmacists assist with patient management," write Barry L. Carter, PharmD, from the University of Iowa and Iowa City Veterans Administration, and colleagues. "The objective of this study was to evaluate if a physician and pharmacist collaborative model in community-based medical offices could improve BP control."

In this study, 402 patients (mean age, 58.3 years) with uncontrolled hypertension were enrolled at 6 clinics, of which 3 clinics were randomly assigned to a control group and 3 clinics were randomly assigned to an intervention group in which physicians and pharmacists underwent team-building exercises. Using national guidelines, clinical pharmacists made drug therapy recommendations to physicians in the intervention group. BP measurements and 24-hour BP monitoring were performed by research nurses.

In the control group, mean guideline adherence scores increased from 49.4 ± 19.3 at baseline to 53.4 ± 18.1 at 6 months (8.1% increase) compared with a 55.4% increase in the intervention group (from 40.4 ± 22.6 at baseline to 62.8 ± 13.5 at 6 months; P = .09 for adjusted between-group comparison).

Decrease in mean BP was 6.8/4.5 mm Hg in the control group compared with 20.7/9.7 mm Hg in the intervention group (P < .05 for between-group systolic BP comparison).

Adjusted difference in BP was ?12.0 mm Hg systolic (95% confidence interval [CI], ?24.0 to 0.0) and ?1.8 mm Hg diastolic (95% CI, ?11.9 to 8.3). Effect sizes were similar for 24-hour BP levels. In the control group, 29.9% of patients achieved BP control compared with 63.9% of patients in the intervention group (adjusted odds ratio, 3.2; 95% CI, 2.0 – 5.1; P < .001).

"A physician and pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates compared with a control group," the study authors write. "Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management."

Limitations of this study include the small number of clinics, factors in the control group that could have made it more difficult to achieve improvements in BP, a higher dropout rate than in a previous efficacy study, and a lack of generalizability beyond community-based family medicine offices. In addition, the findings are not generalizable to patients who are unaware of their hypertension.

"The results of this study suggest that clinics or health systems with clinical pharmacists should consider reallocation of duties to provide more direct patient management to significantly improve [BP] control," the authors conclude. "Future studies of this model should include more clinics with greater geographic, racial/ethnic and socioeconomic diversity because these populations are likely to respond differently to the intervention."

In an accompanying editorial, Helene Levens Lipton, PhD, from the University of California–San Francisco, reviews this and 2 other studies suggesting that team-based interventions enhance quality of care and improve clinical outcomes, albeit with mixed effects on medical service use and costs.

"As the nation once again engages in discussions of health reform, issues of quality and cost containment are high on the agenda," Dr. Levens Lipton writes. "One approach to addressing these challenges is team-based delivery of health care services, including physicians and allied health professionals working collaboratively.... The medical home — a model of comprehensive health care delivery and payment reform that emphasizes the central role of primary care — offers opportunities to implement team-based care and systematically and rigorously evaluate its effects on quality and costs."

A grant from the National Heart, Lung, and Blood Institute supported this study. The Agency for Healthcare Research and Quality Centers for Education and Research on Therapeutics and the Veterans Health Administration supported some of the study authors. Dr. Levens Lipton has disclosed no relevant financial relationships.

Arch Intern Med. 2009;169:1945–1948, 1996–2002.