Pharmacist Management of High Cholesterol Gets More Patients to Goal, Lowers LDL Levels: RxACT

Pharmacists who identify and treat patients with dyslipidemia, including those with inadequately controlled LDL cholesterol levels, are better than physicians at getting patients to goal, according to a new Canadian study.

Overall, patients identified and managed by pharmacists were more than three times more likely to achieve their LDL cholesterol goal compared with physician-directed usual care, report investigators. In total, 43% of patients in the pharmacist-prescribing arm met the Canadian Cardiovascular Society (CCS) targets for LDL cholesterol levels at 6 months compared with just 18% of patients given usual care.

Speaking with TCTMD, senior investigator Glen Pearson, PharmD (University of Alberta, Edmonton, Canada), stressed the importance of healthcare professionals working together within the healthcare system. “This was not an us-versus-them study,” he said. “It was simply, ‘Here’s usual care, what’s already being done.’ We realize people are working to the best of their ability within a strained health delivery system. This is an opportunity to tweak and better focus the context in which patients are interacting with another group.”

The study, which is published in the September/October 2016 issue of the Canadian Pharmacists Journal, included 49 patients randomized to the pharmacist intervention and 50 patients randomized to usual care. In 2007, pharmacists in the province of Alberta were granted the ability to apply for independent prescribing authority, which allows them to prescribe medications. They are also allowed to order and interpret laboratory tests for patients.

As part of the study, which is known as the RxACT trial, pharmacists in the intervention arm assessed each patient’s overall cardiovascular risk, including LDL cholesterol levels, and developed treatment goals and provided counseling for lifestyle changes, such as advice on diet, exercise, and smoking cessation. Importantly, the pharmacists ordered all laboratory tests whenever drug therapy was initiated or a dosage adjusted. The patients received a copy of the laboratory results, their calculated Framingham Risk Score, and an information package on dyslipidemia. They were followed up in person or by telephone at 6, 12, 18, and 24 weeks.

“The bottom line is that nothing was done that couldn’t have been done by many other people,” said Pearson. “We exploited the new abilities of pharmacists to be able to prescribe and to take more control with the patients.”  

Earlier this year, researchers led by Ross Tsuyuki, PharmD (University of Alberta, Edmonton, Canada), who is also the first author of the RxACT study, published data in the Journal of American College of Cardiology showing that the engagement of community pharmacists in the management of patients at high risk for cardiovascular disease improved risk factor control and reduced the likelihood of experiencing a cardiovascular event. In that study, known as RxEACH, there was an absolute 5% lower risk of cardiovascular events among patients managed by pharmacists.  

Pharmacists Well Positioned for Prescribing Role    

In RxACT, the mean LDL cholesterol at baseline in the usual care arm was 124.1 mg/dL and 136.1 mg/dL in the pharmacist-intervention arm. For patients assigned to the pharmacist intervention, LDL cholesterol levels were reduced by 43.3 mg/dL compared with a reduction of 16.2 mg/dL in the usual-care arm (P = 0.001), a difference of 21.1 mg/dL after adjustment.

Based on data from the Cholesterol Treatment Trialists’ (CTT) Collaboration meta-analysis, the sustained LDL cholesterol difference between the two interventions would translate into a 13% reduction in the risk of coronary death or nonfatal MI, a 13% reduction in coronary revascularization, and an 11% reduction in the risk of ischemic stroke, according to the researchers.

Roger Simard, BPharm, a pharmacist in private practice in Quebec and an e-health entrepreneur, told TCTMD that pharmacists, along with nurses, remain underutilized in healthcare and taking advantage of their specific skillsets could improve patient care. “This is something I have felt pharmacists should be allowed to do in several conditions for a very long time, particularly when you think how pharmacists are trained,” said Simard. “The problem is that pharmacists can’t diagnose, but once the diagnosis is made, they are probably in the best position to select the appropriate medications.”

In Quebec, pharmacists are allowed to represcribe a medication previously prescribed by a physician and are allowed to prescribe medications for conditions that do not require a diagnosis, such as nasal corticosteroids for rhinitis and valacyclovir (Valtrex) for cold sores. However, they are not allowed the same prescribing authority as those in Alberta, the lone Canadian province where pharmacists can prescribe medication, said Simard. Pharmacists in Quebec can adjust the dosage of the medication, but only if the therapeutic target is provided by the physician. In this way, the physician remains the “gatekeeper” of clinical care.

“If you don’t have the target, you can’t do anything,” said Simard. “I have to use what the physician gives me.”

Simard recently completed a pilot project in 15 pharmacies using a clinical “dashboard,” one that aggregates patient information from multiple different devices, such as a weight scale, fitness tracker, glucose meter, and a blood-pressure monitor. As part of the pilot project, he still follows 65 patients in his pharmacy. With the dashboard, he can see when patients are not at their optimal blood glucose or blood pressure levels, but there is nothing he can do to correct this outside of referring them back to their physician.

Simard noted that a 2015 advisory panel to the Canadian government on healthcare innovation recommended better collaboration among healthcare professionals. While there is some resistance to allowing pharmacist prescribing, the emergence of clinical data, such as results from the RxACT and RxEACH, make it very difficult to argue against, he added.

Fragmented Health Care in Canada

To TCTMD, Pearson said the undertreatment of patients with dyslipidemia is part of a systemic problem, one that is partly attributable to how healthcare is delivered. In primary care, for example, a general practitioner might see a patient once per year and during that visit is required to cover a number of clinical issues. As a result, it can be difficult to identify at-risk patients.

“We’re often dealing with secondary prevention, working with patients with outcomes secondary to other risk factors, such as heart attack, stroke, or bypass surgery,” said Pearson.

Even when a patient is screened and identified, the initiation and up-titration of medication occurs in a fragmented manner, he noted. Patients who undergo testing can be lost after the initial cholesterol testing, with some patients not returning to the general practitioner for the statin prescription or to have their dosages adjusted.

“There are a variety of challenges in the fragmentation of how care is delivered even once you identify people,” said Pearson. “It’s very difficult. We’re left with the suboptimal management of a problem that isn’t perceived to be a problem until a patient actually has a negative outcome.”

Pearson said RxACT allowed patients increased interaction with pharmacists compared with usual care. Initially, he said, there wasn’t a lot of physician support for pharmacist prescribing, with some doctors concerned it would lead to even more disjointed care. Pearson said a lot of these concerns have been alleviated with regulations in place that require pharmacists to communicate with other members of the healthcare team, including the patient’s physician.

“I think what a lot of people have seen is that based on the relationship pharmacists have with patients, and because of the contact frequency, there is an ability to tap into that knowledge skill and frequency of contact to be able to deliver better care,” said Pearson.

Simard agreed. “Even when you have traditional follow-up, you don’t see patients as often in the medical clinic,” he said. “The pharmacy is open almost every day, 9 or 10 hours. We answer the phone, we talk to patients. It’s much easier to follow people when they need to be followed, when they need coaching, than in the setting of the clinic.”

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