Evaluation of an interprofessional outreach initiative for patients with uncontrolled hypertension in primary care: retrospective cohort study

Document Type

Conference Proceeding

Publication Date


Publication Title

Ohio Pharmacy Residency Conference


Purpose: In a survey published in the Journal of the American Heart Association, medication initiation and treatment intensification among hypertensive patients occurred in only 26.4% and 16% of visits respectively. Additionally, hypertension (HTN) control is a Centers for Medicare & Medicaid Services (CMS) quality metric. In order to improve blood pressure (BP) management, an outreach initiative was started in August 2020. This study aims to evaluate the implementation of an interprofessional outreach initiative with the pharmacy team for patients with uncontrolled HTN in a primary care clinic. Methods: This retrospective cohort study analyzed data from the site’s electronic medical record. Patients were included if they were 18-85 years old, uncontrolled BP or no recorded BP in the past year, and had a telephonic outreach attempt by the clinic pharmacy team. Data was analyzed through March 2021. Patients were excluded using CMS metric exclusion criteria: history of end-stage renal disease, dialysis, renal transplant, or pregnant. Descriptive statistics were used. Results: There were 43 patients contacted, 30 appointments arranged, and 31 medication reconciliations completed. There were 24 appointments attended (3 telehealth appointments). Prior to pharmacy team outreach (n=24): the average BP was 150/87 mmHg,19 patients reported taking HTN medications, and 15 patients were on guideline-directed therapy. At first appointment (i.e. after pharmacy team outreach): the average BP was 136/83 mmHg and pharmacist BP regimen intervention occurred in 14 patients, of which, 9 medications were added, 2 removed, and 5 medication dose increased. Conclusions: In patients with uncontrolled HTN, preliminary results indicate the importance of an outreach initiative to re-engage patients in care, ensure guideline-directed pharmacotherapy, and optimize medications for optimal BP control. Limitations of this study include patient hesitation for in-person clinic visits due to the pandemic. Future directions of this study include follow-up to assess change in blood pressure over time.

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