A number of studies suggest that pharmacists bring unique contributions to the table in working directly with patients on difficult or complicated drug regimens. In fact, models of care that use pharmacists for lipid management, diabetes care, and anticoagulation therapy have been well studied. However, until recently, there were few data showing the effect that clinical pharmacists can have on caring for patients infected with HIV who are beginning treatment with highly active antiretroviral therapy (HAART).
In fact, few healthcare organizations routinely use clinical pharmacists in the care of HIV-infected patients. However, Kaiser Permanente has implemented this type of care at several of its clinics in California, and investigators from Kaiser’s Division of Research in Oakland have just unveiled data suggesting that the approach not only promotes positive clinical outcomes in HIV patients, but also is especially beneficial in disadvantaged populations.1 Further, in clinic settings where pharmacists work directly with HIV patients, researchers find that patients require fewer office visits.
Value is evident in low-income subgroup
The lead investigator on the research, Michael Horberg, MD, MAS, FACP, AAHIVS, wanted to quantify the value or lack of value that pharmacists offer in working with HIV-infected patients, and the Kaiser system presented ideal conditions for an observational study of this sort, because some of the clinics had HIV- clinical pharmacists on staff and some did not.
Horberg strongly suspected that the pharmacists did offer value, but to test that hypothesis he and colleagues analyzed data from more than 1,500 HIV-infected patients who began on HAART between 1977 and 2002. Then, looking at a two-year period, they compared clinical and utilization measures from the patients who received care at clinics that had HIV-clinical pharmacists to similar data from patients cared for at clinics that did not have the specialty pharmacists.
Researchers found that patients who had access to a clinical pharmacist on their care team had two times greater odds of achieving complete viral control, and had a 19% decrease in office visits when compared with the patients who did not receive care from a pharmacist.
The benefits associated with the pharmacist were particularly dramatic among HIV-infected patients residing in low-income areas. Among this subgroup of patients, those who had access to an HIV-clinical pharmacist were three times more likely to achieve total viral control than were patients who did not have access to a pharmacist.
The effect on utilization in this subgroup was striking as well: Patients with access to a pharmacist had 66% fewer days of hospitalization and 43% fewer office visits than patients who did not have access to a pharmacist.1
“These are patients who probably can’t navigate the system as well and end up in the ER and in the doctor’s office more often because of poverty-related life stressors,” says Horberg. “The clinical pharmacist is there to help mitigate a lot [of these issues] and provide better access to the system.”
Compliance is challenging
In fact, the responsibilities of the HIV clinical pharmacist vary somewhat from clinic to clinic in the Kaiser system, but Horberg says organizational policy requires every patient starting on HAART to consult with the pharmacist in every clinic where one is on staff. During these sessions, the pharmacist educates patients about why they need to take their medicines and how to take them correctly. Further, he or she will discuss potential side effects and how to manage them if they occur.
Jennifer Yu, PharmD, the HIV-clinical pharmacist in Kaiser’s Santa Clara, CA, clinic, says that she also spends a lot of time working with patients to establish a medication schedule that will work for them, because compliance is especially challenging in this group. “We are asking a lot from these patients,” she says. “We are asking them to comply with their medicine at least 95% of the time, because that is what the literature tells us is what they need to ensure viral suppression.”
Once patients understand what the consequences are of noncompliance, they are often more willing to change their work schedule or make other adjustments that will enable them to take their medications as directed, adds Yu. However, she also counsels patients on strategies that can help them to be more compliant.
“If the medicine has to be taken with food once a day, I will find out what is the most regular meal for a patient so they can take the medicine every day at that time,” she says. “Alternatively, in cases where patients don’t like to bring their medications to work, the evening is a better time to take their medications. So, I sit down with the patient and come up with a plan, but it is very individualized.”
Pharmacists advise patients and clinicians
In addition to having in-person office visits with all of the patients starting on HAART, Yu also acts as a case manager for a large number of the patients she sees. This involves making follow-up calls at two, four, and six weeks after patients have started on HAART. During these communications, Yu will address any problems the patients are experiencing, and with the help of pharmacy claims information to which she has access, Yu makes sure that patients continue to be compliant.
“I also check to see if they have started taking any new prescription or over-the-counter medications that could interact with the HIV medications,” she explains. “I make sure they have undergone appropriate blood tests based on the medications they are taking, and that they have appointments scheduled with their doctor on a regular basis.”
Additionally, given the close working relationship she establishes with patients, Yu is often the person they call when they have questions or experience difficulties managing their disease. In many cases, Yu can resolve the problem herself by phone, but when appropriate she communicates with the physician to find out what further action he or she recommends. In cases involving drug interactions or troubling side effects, Yu typically works with the physician to resolve the issue.
It is not unusual for Yu to encounter patients who have difficulty affording the drugs prescribed to them. In these cases, she usually refers patients to a benefits coordinator on staff at the clinic who can assist patients in linking up with pharmacy assistance programs.
In addition to consulting with patients, the HIV-clinical pharmacists also are available to physicians who may have questions or concerns about various therapeutic approaches. Horberg observes that the added input and assistance provided by the pharmacists are largely appreciated by physicians, but he cautions that this may be partly a result of the unique characteristics of the Kaiser system. “We utilize clinical pharmacists a lot for complex chronic conditions,” he says. “There is a culture in place that values [the approach].”
Yu agrees, noting that physicians appreciate having another professional on hand to make sure that appropriate care is provided and up to date. Further, she observes that physicians are mindful of the personalized care and attention that pharmacists are able to provide to their patients.
Further study is needed
Although investigators found that the HIV-clinical pharmacists were associated with improved adherence and reduced office visits, they did not find any correlating improvement in CD4 T-cell counts, which are a measure of viral control. “With the use of HAART, both groups had significant increases in the CD4 T-cell counts, but the rise in either group was not significantly different from the other,” adds Horberg, noting that this is a result he cannot explain, given that improvements in adherence should be associated with improved CD4 T-cell counts (see Figure 1 below).
Additionally, as Horberg only looked at the role of the HIV-clinical pharmacist, it is unclear whether another type of personnel might be able to provide similar benefits in terms of boosting medication compliance. Horberg hopes to look at the contributions of other healthcare professionals in future studies, but he points out that the current study already suggests that clinical pharmacists may well be an underutilized resource—especially in the public health sector.
1 Horberg M, Hurley L, Silverberg M, et al. “Effect of Clinical Pharmacists on Utilization and Clinical Response to Antiretroviral Therapy.” Journal of Acquired Immune Deficiency Syndromes. Copyright 2007 Lippincott Williams & Wilkins, Inc.