Improving hypertension management through pharmacist prescribing; the rural alberta clinical trial in optimizing hypertension (Rural RxACTION): trial design and methods
The Canadian Hypertension Education Program (CHEP) has the mandate of reducing the burden of cardiovascular disease in Canada through optimized hypertension management. The process of screening, diagnosing, treating, and monitoring hypertension on an ongoing basis generates the single greatest number of family physician office visits in Canada—more than 20 million visits annually.1 This represents a substantial workload for physicians. Complicating the matter is the fact that approximately 15% of the Canadian population currently does not have a family physician. Moreover, the prevalence of diagnosed hypertension is growing: approximately 1 in 4 Canadians is affected and this is expected to increase. In those older than 50 years of age, a recent Canadian population analysis reports the prevalence of hypertension as greater than 50%.2 In a national survey done between 1986 and 1992, only a minority of patients with hypertension were identified, treated, and controlled to their recommended blood pressure target.3 Rates of hypertension control have improved, according to a recent survey in Ontario, but at least 30% of Ontarians 18 years of age or older were still either uncontrolled or not identified.4 For these reasons, the Implementation Task Force (ITF) of CHEP felt it would be beneficial to acknowledge the existing care gap in the management of hypertension and encourage primary health care professionals to further integrate and coordinate their efforts with the ultimate goal of decreasing the burden of cardiovascular disease. Given the prevalence of hypertension and the large patient care demands already placed on family physicians, one solution for the screening and care of patients with hypertension is to take full advantage of the special knowledge, skills, and abilities of other members of the health care team. The ITF committee comprises 3 primary care subgroups: family physicians, nurses, and pharmacists. At the annual ITF meeting in September 2007, it was identified that the collaboration of various health care professionals can be hindered by the lack of clarity regarding the role of each professional group in the management of patients with hypertension. Given the multidisciplinary nature of CHEP and the ITF, we felt it was important for us to endorse interdisciplinary collaboration and explore how it could be further enhanced. Currently, there is little data to demonstrate if or how collaborative care affects patient outcomes; however, it seems intuitive that hypertension control will be enhanced if all team members’ special skill sets are used to the fullest. The family physician has traditionally been central to the coordination of care for the patient. The changing scope of practice for nurses, nurse practitioners, and pharmacists, however, is facilitating their greater involvement in chronic disease management. Further, increasing numbers of patients with hypertension coupled with the demands on family physicians suggests that collaboration in care is essential. Although interdisciplinary teams (such as primary care networks or family health teams) either exist or are being created to incorporate other health professionals into primary health care, this concept is still in its infancy and likely affects a minority of patients with hypertension. Instead, the bulk of care is happening at the traditional family practice level in which the infrastructure and financial resources to facilitate routine interdisciplinary care are lacking. The intent of this paper is to generate discussion on how we can collaboratively improve care in our respective communities by sharing responsibility, with the common goal of improving hypertension management in Canada. In doing so, we hope to identify gaps in our current knowledge that might help researchers. We hope that our endorsement of interdisciplinary collaboration will encourage further research aimed at determining whether such collaboration results in enhanced outcomes for patients with hypertension. We acknowledge the overlapping roles among physicians, nurses, and pharmacists; this paper will highlight the unique skill set of each group, which can contribute to enhanced patient management (Figure 1).