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The study was implemented across two
phases. Phase 1 (the pre-intervention arm)
represented the standard 'physician-alone
managed hypertension model', where
the physician did not receive advice
regarding BP management from a clinical
pharmacist. Phase 2 (the intervention
arm) utilised a 'pharmacist-physician
collaborative model', consisting of targeted
hypertension management education
and ongoing collaborative management.
The education process aimed to
standardise the participating physicians'
knowledge of National Heart Foundation
(NHF) Hypertension Guidelines11
through dissemination of the guidelines,
presentation of retrospective data and
a short self-test consisting of three
hypothetical case studies. This process
sought to enable improved recognition of
suboptimal BP control and to encourage
appropriate anti-hypertensive therapy
changes in order to reach SBP targets.
Targets were set in accordance with
the guidelines current at the time of
the study, BP <140/90 mmHg for those
with uncomplicated hypertension and
BP <130/80 mmHg for patients with
a history of coronary heart disease,
diabetes, stroke or chronic kidney
disease as tolerated by the patient.
The interactive 'pharmacist-physician
collaborative model' consisted of
the pharmacist reviewing a patient's
medical file and conveying therapy
recommendations to the physician.
An active dialogue between the clinical
pharmacist and physician regarding the
subject's treatment was encouraged, for
example, by recommending appropriate
anti-hypertensive therapy changes
(either an increase in the dosage of
an antihypertensive or the addition
of a new antihypertensive). Less than
10 minutes was expended to review each
subject's BP control and for subsequent
communication with the doctors.
Ethical approval for this study was
obtained from the local institutional
Human Research Ethics Committee.
Informed consent from patients
and physicians was obtained prior
to recruitment for the prospective
intervention arm. The project was
exempted from obtaining subject consent
for the retrospective pre-intervention arm.
Sample size was calculated based on
data from Carter, et al.7 which examined
differences in BP control with and
without a pharmacist involvement.
This pharmacist-physician collaborative
study obtained a mean BP reduction of
20.7/9.7 mmHg compared to a reduction
of 6.8/4.5 mmHg without the involvement
of a pharmacist after a 6-month period.
Sample size was calculated using G* Power
(version 3.0.10).9 Using an alpha of 0.05
(2 tailed) and power of 80%, an estimated
sample size of 94 patients (47 patients in
each group) was calculated to detect a
difference of 6--10 mmHg in SBP.
This study targeted consecutive admissions
to a 60 bed stand-alone specialist
rehabilitation hospital. Subjects with a
history of hypertension were eligible
for inclusion. Subjects were excluded
if they had uncontrolled hypertension
associated with sepsis, significant
drug-disease interactions (e.g. non-steroidal
anti-inflammatory drugs which can
potentially antagonise antihypertensive
therapy), were non-compliant with hospital
management and/or whose hospital
length of stay was less than five days.
Physician participants in the study were four
rehabilitation specialists and two accredited
Subject recruitment is summarised in
Figure 1. For the pre-intervention arm,
medical records of consecutive admissions
to the hospital from December 2009 to
March 2010 (inclusive) were screened
against inclusion and exclusion criteria
and a sample of 60 patients was identified.
For the intervention arm, consecutive
admissions were screened and eligible
patients were approached for consent from
May 2010 until August 2010 (inclusive)
resulting in a sample of 50 patients. A total of
135 patients were screened for recruitment,
17 screened patients did not meet the study
criteria and 8 patients refused to consent.
Data collected included patient
characteristics (age, sex, reason for admission,
number and type of medical co-morbidities
and medication use), BP on admission and
during the last five days of hospital stay
and the nature of therapy changes (dose
adjustment/addition of a new agent) to
anti-hypertensive medications. Data were
transposed to a database for statistical
analysis. The data for five patients (two in the
pre-intervention and three in the intervention
arm) were subsequently excluded as they
remained hypotensive throughout their
hospital stay. The primary outcomes studied
were the number of modifications to
antihypertensive therapy, the proportion
of patients who achieved target BP, and the
change in SBP from admission to discharge
between the two groups.
Data was processed in SPSS (version 18).
Mean and standard deviation for interval
data and median and inter-quartile range
were calculated for ordinal level data.
Patient characteristics were examined for
between-group differences at baseline.
Data were checked for normality using the
Kolmogorov-Smirnov test. Between-group
differences for nominal level variables were
assessed using Chi-square analysis; Mann
Whitney U tests were used for ordinal level
differences or non-normally distributed
variables. For interval/ratio level variables,
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