Addition of a pharmacist to the interdisciplinary primary care team will improve blood pressure control in patients with type 2 diabetes
Health Research Ethics Board (Biomedical), University of Alberta. Date of original approval February 2004; updated annually. HREB (B) file number 5137.
Randomized, controlled study
Primary study design
Secondary study design
Randomised controlled trial
Patient information sheet
Type 2 diabetes mellitus
Intervention programs that successfully improve management of chronic diseases share similar characteristics. First, a framework of explicit care plans (or critical pathways) is used to guide patient care. Second, the practice setting is restructured to involve an interdisciplinary team approach that will meet the needs of the patients. Third, attention is given to the information and support needs of the patient as they change health-related behaviours. Fourth, access to necessary expertise should be available for both the patient and the health care providers when needed. Fifth, an integrated information system is used for record-keeping and coordinating provision of ongoing care and follow-up. The environment created by the Primary Care Networks in our health region facilitates the development of these characteristics.
The intervention is essentially the addition of a pharmacist to an interdisciplinary care team within community family physician clinics. The pharmacist will work as a member of the interdisciplinary care team to provide information on drug therapy and take responsibility for monitoring therapeutic outcomes for all of the patients conditions to ensure effective use of medications. Activities specifically related to this study include:
1. Identification of any patient-perceived barriers to medication use and provision of patient-specific instructions to improve adherence
2. Identification of any drug-related problems pertaining to blood pressure control and provision of any necessary recommendations to optimize therapy
3. Recommendations to use acetylsalicylic acid, if indicated. These activities will be provided to the patient in addition to the regular services provided by the interdisciplinary care team.
During the first visit, which is expected to take 1 hour, the pharmacist will obtain a complete medication history to identify all prescription, non-prescription, herbal, and homeopathic drug products the patient currently uses. The pharmacist will obtain the patients medical history from discussion with the interdisciplinary team members, the physician office chart, and patient report. A limited physical exam will be performed to obtain the patients current blood pressure using the BpTRU. The BpTRU is an automated blood pressure device that has good accuracy and reliability compared to a mercury sphygmomanometer. Responses to the Barriers to Medication Use component of the baseline survey will be used to identify any difficulties with medication adherence. The pharmacist will record his/her observations on standardized report forms and use a systematic approach to process the information to identify any actual or potential drug-related problems. Recommendations for changes to the patients drug therapy will be communicated both verbally and in writing by the pharmacist directly to the health care team in the physician office.
Improvement of medication adherence will be the first major focus of the pharmacist intervention. Based on recent systematic reviews in adherence, a multifaceted approach is the most effective for improving adherence rates. The pharmacist will use written and verbal instructions to educate the patients about the name, purpose, and appropriate use of each prescription medication. The patient will be encouraged to ask questions about their medications and the pharmacist will take the time to address these concerns. Recommendations to simplify the medication will be made, where indicated. For example, drugs that are administered once-daily and combination drug formulations will be recommended where possible. Cuing techniques (e.g. coordinating administration time with a daily event, use of blister packaging) will be used to incorporate medication consumption into the patients daily routine. Support mechanisms, such as close telephone follow-up, involvement of the patients family, and group teaching sessions will be used. We have found in discussions with heart failure patients that these techniques helped them maintain good adherence rates.
The second major focus of the pharmacist intervention is to identify and resolve drug-related problems. Interventions to resolve these problems would include, for example:
1. Comprehensive and individualized education on diabetes, cardiovascular risk factors, and the importance of reaching treatment goals for blood pressure, cholesterol, and acetylsalicylic acid use
2. Education on the impact of lifestyle choices (diet, exercise, and smoking) on cardiovascular risk
3. Education on the benefits and risks of drug therapy
4. Treatment recommendations for the individuals primary care physician
Treatment recommendations for hypertension and hypercholesterolemia management and acetylsalicylic acid use will be based on management algorithms. These algorithms are being developed from current Canadian guidelines, existing algorithms, treatment protocols from randomized controlled studies, and advice from local opinion leaders, family physicians, and allied health care professionals. For example, recommendations for hypertension management will follow a stepped care approach and an algorithm to determine indications for prophylactic use of acetylsalicylic acid was recently published.
Interim visits with the intervention group subjects will be arranged as clinically necessary. These visits may be conducted either over the phone, or in-person. This contact time will be used to identify any patient concerns about the medication regimen and determine if an in-person follow-up visit is required. In-person follow-up visits, estimated to take 15-20 minutes, will contain an abbreviated medication history to update any changes in drug therapy since the last visit and perform a limited physical exam to obtain the patients current blood pressure. The pharmacist will then determine if there are any drug-related problems; most notably to determine if the treatment target for blood pressure has been achieved.
At the 12-month follow-up visit, the patient will be asked to complete the same self-administered survey given at enrollment. The pharmacist will obtain a blood pressure measurement and a fasting blood sample will be drawn to determine blood glucose levels, A1c, and a lipid profile.
Patients enrolled in the control group will not interact with the clinic pharmacist until the end of the 12-month follow-up period. Their care will be managed by the interdisciplinary care team. Baseline information on current prescription medications and clinical data, including blood pressure, will be obtained from the office chart. At the end of the 12-month follow-up, all patients will be asked to attend an in-person clinic visit with the pharmacist. The pharmacist will conduct an interview similar to the baseline interview for the intervention subjects. Fasting blood sample will be drawn to determine blood glucose levels, A1c, and a lipid profile.
Primary outcome measures
Proportion of subjects achieving a 10% reduction in systolic blood pressure from baseline
Secondary outcome measures
1. Differences in systolic blood pressure (BP) changes between groups
2. Proportion of subjects achieving the BP target of <130/80
3. Differences in A1c changes between groups
4. Differences in low-density lipoprotein (LDL) changes between groups
5. Difference in 10-year risk of cardiovascular disease as calculated by
a. Framingham risk score
b. United Kingdom Prospective Diabetes Study (UKPDS) risk equation
Process-based variables, adjustment in drug therapy
6. Initiate regular aspirin use for cardiovascular disease prevention
7. Initiate angiotension-converting enzyme (ACE) inhibitor therapy for vascular protection
8. Change to antihypertensive therapy
9. Change to lipid-lowering drug therapy
10. Difference in adherence rate to antihypertensive drug therapy between groups
11. Difference in proportions of subjects having Canadian Diabetes Association guideline-based recommendations in past year
12. Measurement of A1c (outside of protocol-driven measure at study end)
13. Measurement of fasting lipid profile (outside of protocol-driven measure at study end)
14. Measurement of creatinine ratio (ACR)
15. Measurement of urinary albumin
16. Eye examination for retinopathy
17. Foot examination by a health care professional
Overall trial start date
Overall trial end date
Participant inclusion criteria
Subjects with type 2 diabetes, who are not considered for urgent assessment by the Regional Diabetes Program (i.e. those with A1c <0.08, blood pressure <220/120, or triglycerides <15 mmol/l)
Target number of participants
400 (200 in intervention arm & 200 in control arm)
Participant exclusion criteria
1. Subjects currently followed in specialty clinics for management of hypertension, hyperlipidemia, or diabetes
2. Those who decline an invitation to participate
3. Those who are cognitively impaired (i.e. unable to give informed consent)
3. Those who are not responsible for their own medication consumption
4. Those who are unable to communicate in English
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
3126 Dentistry Pharmacy Centre
Canadian Diabetes Association
1400 - 522 University Avenue
Canadian Diabetes Association and the Institute of Health Economics
Funding Body Type
Funding Body Subtype
Results and Publications
Publication and dissemination plan
Not provided at time of registration
Intention to publish date
Participant level data
Not provided at time of registration
Results - basic reporting
1. 2012 results in http://www.ncbi.nlm.nih.gov/pubmed/22486226
Ladhani NN, Majumdar SR, Johnson JA, Tsuyuki RT, Lewanczuk RZ, Spooner R, Simpson SH, Adding pharmacists to primary care teams reduces predicted long-term risk of cardiovascular events in type 2 diabetic patients without established cardiovascular disease: results from a randomized trial., Diabet. Med., 2012, 29, 11, 1433-1439, doi: 10.1111/j.1464-5491.2012.03673.x.