hypertension case study pharmacy

Pharmacy Briefing Event: Join us to discuss critical pressures and the future of the sector

Learn more about community pharmacy

Search Suggestions

• Our Committee
• Meeting Agendas & Minutes
• Structure & Governance
• Annual Report & Accounts
• Vision & Strategy
• The Negotiating Process
• Five-Year CPCF (Overview)
• Latest Negotiation Updates
• NHS Long Term Plan
• Communications & Public Affairs
• Responses To Consultations
• Transforming Pharmacy Representation (TAPR)
• Latest News
• Newsletter Sign-Up
• Our Briefings Database
• Our Webinars
• Discount Deduction
• Funding Distribution
• Indicative Income Tables
• Margins Survey
• Pre-registration Training Grant
• Our Ongoing Funding Work
• Retained Margin (Category M)
• Summary of Funding Changes
• Payment Timetable
• Schedule Of Payments
• Branded Generics
• Dispensing At A Loss
• Endorsement Guidance
• Payment & Pricing Accuracy
• Price Change Mechanism
• Price Concessions
• Report Product Over Drug Tariff Price
• Retrospective top-up payments
• Temporary Safeguarding Payments
• Clinical Services Statistics
• Community Statistics
• EPS & IT Statistics
• Flu Vaccination Statistics
• NMS Statistics
• Remuneration Statistics
• Consolidations (Mergers)
• Contract Monitoring
• Market Entry
• Opening A Pharmacy
• Opening hours (including unplanned temporary closures)
• Pharmaceutical Needs Assessment (PNA)
• Pharmacy Access Scheme
• Relocations
• Terms of Service changes
• PLPS Regulations May 2023 Amendements
• Business Continuity Planning
• Managing a temporary pharmacy closure
• Clinical Audit
• NHS Complaints Procedure
• Patient Satisfaction Survey
• Practice Leaflet Requirements
• Safety Incident Reporting
• Security and personal safety
• Terms of Service: Important dates
• PQS Outcomes
• Annual workforce survey
• Direction of Prescriptions
• Distance Selling Pharmacies
• Equality Act
• Fitness To Practise
• Hub & Spoke Dispensing
• Original Pack Dispensing
• Responsible Pharmacist
• Controlled Drugs
• Dispensing A Prescription
• Drug Tariff Resources
• Medicinal Products
• Special Containers
• Split Pack Dispensing
• Unlicensed Specials & Imports
• Virtual Drug Tariff
• Our Briefings: Dispensing & Supply
• Manufacturer Contingency Arrangements
• Medicine Shortages
• Serious Shortage Protocols
• Shortage Reporting Form
• How Prescriptions are Processed
• Is This Item Allowed?
• Patient Charges & Exemptions
• Prescription Form Validity
• Prescription Submission
• Receiving A Prescription
• Reimbursement
• Dispensing Medicines
• Repeat Dispensing/eRD
• Dispensing Appliances
• Discharge Medicines Service
• Public Health
• Healthy Living Pharmacy
• Signposting
• Disposal or unwanted meds
• Our Briefings: National Pharmacy Services
• CPCF services: Important dates
• Appliance Use Reviews
• Flu Vaccination Service
• Hypertension Case-Finding
• LFD service
• Pharmacy Contraception Service
• Pharmacy First service
• Smoking Cessation Service
• Stoma Appliance Customisation
• COVID-19 Vaccination Service
• Comms & Connectivity
• Directory of Services (DoS)
• NHS Databases & Profiles
• Manage Your Service (MYS)
• Suppliers Hub incl contacts
• EPS Dispensing
• EPS Submission
• EPS Prescription Tracker
• Medicines Database (dm+d)
• RTEC Exemption Checking
• GP Connect: Update Record
• Data security (DS) hub
• DS Protection Toolkit
• Pharmacy Records Retention
• Shared Care Records (ShCR)
• Summary Care Record (SCR)
• CPCF IT requirements & MYS APIs
• CP IT Group
• Contingency Planning
• Get Involved With IT
• Patient Digital Services
• Reporting Issues & Feedback
• Training & capabilities
• LPCs In The Spotlight
• LPC Websites
• News: LPCs & Local
• LPC Members Area
• LPC Member Changes Form
• Glossary of Acronyms
• Think Pharmacy
• Working With Commissioners
• Working With GPs
• Facts, Stats & Quotes
• Integrated Care Systems
• Locally Commissioned Services
• Local Services Database
• Primary Care Networks
• Back to Main Menu
• Back to About us
• Meeting Agendas & Minutes
• Structure & Governance
• Annual Report & Accounts
• Vision & Strategy
• Back to Negotiations
• Negotiations
• Back to Representing pharmacy owners
• Representing pharmacy owners
• Communications & Public Affairs
• Back to Updates & Events
• Updates & Events
• Funding & Reimbursement
• Back to Funding
• Back to Monthly Payments
• Monthly Payments
• Back to Reimbursement
• Payment & Pricing Accuracy
• Back to NHS Statistics
• NHS Statistics
• EPS & IT Statistics
• Quality & Regulations
• Back to Contractual Framework
• Contractual Framework
• Back to Clinical Governance etc.
• Clinical Governance etc.
• Back to Pharmacy Quality Scheme
• Pharmacy Quality Scheme
• Back to Regulations
• Regulations
• Hub & Spoke Dispensing
• Dispensing & Supply
• Back to Dispensing
• Unlicensed Specials & Imports
• Back to Supply Chain
• Supply Chain
• Back to Prescription Processing
• Prescription Processing
• Patient Charges & Exemptions
• National Pharmacy Services
• Back to Essential Services
• Essential Services
• Back to Advanced Services
• Advanced Services
• Back to National Enhanced Services
• National Enhanced Services
• Digital & Technology
• Back to Systems & Suppliers
• Systems & Suppliers
• Comms & Connectivity
• NHS Databases & Profiles
• Back to Digital Dispensing
• Digital Dispensing
• Back to EPS Home
• Back to Records, Data Security & IG
• Records, Data Security & IG
• Back to Digital & Shared Care Records
• Digital & Shared Care Records
• Back to Tech, Policy & Development
• Tech, Policy & Development
• CPCF IT requirements & MYS APIs
• Back to IT Policy & Development
• IT Policy & Development
• Reporting Issues & Feedback
• Training & capabilities
• LPCs & Local
• Back to About LPCs
• News: LPCs & Local
• Back to For LPCs
• Back to Local Engagement
• Local Engagement
• Back to Local Commissioning
• Local Commissioning
• Facts, Stats & Quotes

Hypertension Case-Finding Service

Published on: 23rd August 2021 | Updated on: 17th April 2024

This page contains information about the Hypertension Case-Finding Service which was commissioned as an Advanced service from 1st October 2021.

In public-facing communications, the service is described as the NHS Blood Pressure Check Service.

From 1st December 2023 , the service can be provided by suitably trained and competent pharmacy staff; previously, only pharmacists and pharmacy technicians could provide the service.

Where non-registered pharmacy staff provide the service, until clinical IT systems are updated to allow their names to be entered within the clinical record, the name and GPhC registration number of the responsible pharmacist should be included in the clinical record.

DHSC publicity campaign launches 11th March

The Department of Health and Social Care will be launching a campaign to promote the Hypertension Case-Finding Service from 11th March 2024.

A TV, social media, public relations and billboard campaign will encourage those aged 40 years and over, to get a free blood pressure check at the nearest participating pharmacy. The public will be encouraged to search for participating pharmacies via the  NHS Check your blood pressure tool .  

Pharmacy owners providing the service, can order a free pharmacy campaign pack from the  Campaign Resource Centre  to promote and support the campaign.

Read our news story for further information 

Click on a heading below for more information Introduction

The 5-year Community Pharmacy Contractual Framework (CPCF) agreement reached in July 2019 included a plan to pilot case-finding for undiagnosed cardiovascular disease.

In 2020, NHS England commenced a pilot involving pharmacies offering blood pressure checks to people 40 years and over. In some pharmacies within the pilot, where the patient’s initial blood pressure reading was elevated, they would be offered ambulatory blood pressure monitoring (ABPM), which is the gold-standard for diagnosis of hypertension.

Following the initial findings of the pilot, the Department of Health and Social Care (DHSC) and NHS England proposed the commissioning of a new Hypertension Case-Finding Service, as an Advanced service, in the Year 3 negotiations.

The policy background

Cardiovascular disease (CVD) is one of the leading causes of premature death in England and accounts for 1.6 million disability adjusted life years.

Hypertension is the biggest risk factor for CVD and is one of the top five risk factors for all premature death and disability in England.  An estimated 5.5 million people have undiagnosed hypertension across the country.

CVD is a key driver of health inequalities, accounting for around 25% of the life expectancy gap (27% in men and 24% in women) between rich and poor populations in England. Those in the most deprived 10% of the population are almost twice as likely to die as a result of CVD than those in the least deprived 10% of the population. Additionally, 60% of excess mortality for those living with severe mental illness can be attributed to preventable physical health conditions, such as heart disease.

Residents of the most deprived areas in England are 30% more likely to have high blood pressure (BP) compared to those in the least deprived areas. Community pharmacy BP monitoring has the potential to increase the detection of hypertension within local populations and is expected to positively impact health inequalities by targeting people who do not routinely see their GP or use other NHS services.

The NHS Long Term Plan commits the NHS to reducing morbidity and mortality due to CVD, tackling inequalities and a shift towards prevention strategies. It specifically states that community pharmacy, in collaboration with other providers, will provide opportunities for the public to check on their health through tests for high BP and other high-risk conditions.

In February 2019, as part of the Cardiovascular Disease Prevention System Leadership Forum, NHS England published new national ambitions for the detection and management of the high-risk conditions. The ambition for hypertension is that 80% of the expected number of people with high BP are detected by 2029, and that 80% of the population diagnosed with hypertension are treated to target. At the time of publication of the NHS Long Term Plan, NHS England and Public Health England estimated less than 60% of people with hypertension had been diagnosed.

The aims of the service

The service aims to:

• Identify people aged 40 years or older, or at the discretion of pharmacy staff, people under the age of 40, with high blood pressure (who have previously not had a confirmed diagnosis of hypertension), and to refer them to general practice to confirm diagnosis and for appropriate management;
• At the request of a general practice, undertake ad hoc clinic and ambulatory blood pressure measurements. These requests can be in relation to people either with or without a diagnosis of hypertension; and
• Provide another opportunity to promote healthy behaviours to patients.

Service specification and other documentation

The service requirements are included in the  service specification , which  pharmacy owners must read  before deciding whether to provide the service.

Download the service specification

Service specification Annex A – Blood pressure check process flowchart

Service specification Annex B – Guidance on clinic blood pressure check

Service specification Annex C – Clinic BP flowchart

Service specification Annex D – ABPM flowchart

Service Directions & Determination  (published September 2021)

Briefing 035/23: Updated guidance on the Hypertension Case-Finding  (22nd November 2023) This Community Pharmacy England Briefing provides additional guidance for pharmacy owners and their teams on the service.

The service has two stages – the first is identifying people at risk of hypertension and offering them a blood pressure measurement (a ‘clinic check’).

The second stage, where clinically indicated, is offering ambulatory blood pressure monitoring (ABPM). The blood pressure test results will then be shared with the patient’s GP practice to inform a potential diagnosis of hypertension.

Pharmacy owners opting to provide the service must undertake both stages of it, where clinically required, i.e. it is not possible to just undertake clinic BP readings and not ABPM.

The service should be provided by suitably trained and competent pharmacy staff. The Responsible Pharmacist must ensure that delegated tasks are being undertaken safely by competent pharmacy staff.

The pharmacy owner must ensure all pharmacy staff providing the service are appropriately trained and that clinical supervision for the service is being provided by the pharmacist.

Getting ready to provide the service

BP meters to be used in the service

As part of preparations to provide the service, pharmacy owners will need to purchase or rent equipment for each of the two stages of the service – Clinic blood pressure check and ABPM – unless they already have equipment which meets the required standards.

Equipment that is to be used in the service must be validated by the British and Irish Hypertension Society (BIHS), so pharmacy owners must use a ‘normal’ BP meter and an ABPM which are included on one of the two following BIHS lists:

Validated BP Monitors for Home Use

Validated BP Monitors for Specialist Use

Points to note:

• ABPMs must be reset for each service user;
• To meet the service specification requirements, validation, maintenance and recalibration of both clinic blood pressure monitors and ABPM devices should be carried out periodically according to manufacturers’ instructions; and
• Infection control measures and cleaning must be carried out as per the instructions of the manufacturer or supplier and in line with current infection control guidance.

Considerations before purchasing/renting equipment

Pharmacy owners may find it useful to refer to the  Medicines and Healthcare products Regulatory Agency guidance on the purchase, management and use of blood pressure measurement devices  and the  Point of care testing in community pharmacies guide  when selecting equipment for this service.

Before a decision is made about the purchase or rental of equipment, there are several considerations pharmacy owners may need to think through to ensure they have weighed up the additional requirements, implications and costs associated with provision of the service when using their selected equipment.

A non-exhaustive list of some of the considerations can be found below:

• Is maintenance and training included in the purchase price?
• If equipment is broken or being calibrated, does the supplier provide a spare whilst it is being repaired/calibrated?
• Calibration versus replacement cost and the carbon footprint of both activities;
• Frequency/cost of cuff replacement and other consumables;
• Complexity of use – time taken to use (and explain use, in the case of ABPM);
• For clinic meters, do they automatically take 3 measurements and flag irregular pulse (this feature is very beneficial, but optional)?
• For ABPM, the usability of any inclusive software to support set up for the patient and interpretation of readings. Additionally, software and hardware compatibility with existing pharmacy IT systems needs to be considered, e.g. can you plug the meter into a USB port on a PC in the pharmacy; and
• Insurance to cover accidental damage to either type of meter and to cover the theft or failure of a patient to return ABPM.

Training requirements

To provide the service, pharmacy staff must:

• Be familiar with parts of  NICE guideline Hypertension in adults: diagnosis and management [NG136] relevant to the role they are undertaking within the service;
• Have read and understood the operational processes to provide the service as described in the service specification; and
• Have completed the recommended training on how to use the blood pressure monitoring equipment which should be provided by the equipment manufacturer/supplier.

A checklist to provide suggested actions that pharmacy staff can undertake to prepare to provide the service is available.

Download the Hypertension Case-Finding Service staff training checklist (April 2024)

Additional optional training

Pharmacy staff wanting to undertake further training on hypertension, understanding vascular risk and behaviour change interventions can do so on an optional basis to support their own continuing professional development (CPD).

Support with additional CPD can be found on the:

• CPPE hypertension case-finding service page
• Pharmacy courses page  of the Health Academy website.

Pharmacy team training

The whole pharmacy team can proactively promote this service and support with the recruitment of patients. Teams should be briefed on the service and coached on how to best approach people about the service.  A pharmacy team  briefing and a guide on how to recruit patients  is available to assist pharmacy owners to engage and coach their team members.

Download the Community Pharmacy England Briefing for pharmacy teams on the service (22nd November 2023)

Consultation room

Pharmacies must have a consultation room that will be used for the provision of the service which meets the requirements in the Terms of Service. The consultation room should also comply with the following requirements:

• When measuring blood pressure, the patient must be able to rest their arm on a table/bench at a suitable height; and
• It must have IT equipment accessible within the consultation room to allow contemporaneous records of the consultations provided as part of this service to be made.

Provision other than in the pharmacy consultation room

In agreement with the local NHS contract management team, potential patients may be targeted and the service could be provided in other settings outside the pharmacy such as areas not designated part of the pharmacy within supermarkets or large stores or in community locations such as community centres, sports grounds and places of worship.

Provision other than in the pharmacy, can be considered for occasional approval, and should not be sought for the same site being used frequently for delivery of the service in a manner that may undermine the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 (PLPS) by setting up locations where pharmaceutical services are offered that are not pharmacies.

Off-site provision could therefore, support pharmacy owners with occasional provision, as part of approaches to support external provision of health promotion in communities in line with Health Living Pharmacy requirements.

Details for the principles that the local NHS contract management team decision-makers may consider, are outlined in guidance, which can be accessed via the below link. The guidance also provides a template that pharmacy owners will need to use to make a request for offsite provision to their local NHS contract management team.

Key Documents – NHS England Pharmacy Integration Programme – FutureNHS Collaboration Platform  (Log-in required)

Requests for off-site provision should be submitted to your local NHS contract management team. Contact details for your local NHS contract management team can be found  here .

Where the service is provided from premises other than the registered pharmacy premises, pharmacy owners must ensure the location is appropriate for service provision (i.e. meets standards required by the General Pharmaceutical Council and that patient confidentiality can be maintained). It is recommended that a risk assessment is also undertaken to identify and minimise risks to patient safety and impact on wider pharmacy services.

Provision from premises other than the registered pharmacy premises must be under the supervision of a pharmacist who is available to provide clinical advice where required.

Sign up to provide the service

Pharmacy owners must notify NHS England that they intend to provide the service by completion of an electronic registration through the NHS Business Services Authority’s (NHSBSA)  Manage Your Service (MYS) application .

Standard Operating Procedure

Pharmacy owners must have a Standard Operating Procedure (SOP) for the service, which all staff participating in provision of the service must be familiar with and follow. SOPs must include the process for maintenance and validation of the equipment used.

Various pharmacy support organisations provide template SOPs which their members can personalise for use in their pharmacy.

Following changes to the service specification, pharmacy owners are advised to review any existing SOPs for the service, to ensure any relevant changes to these SOPs have been made. When developing or updating the SOP, pharmacy owners will need to decide the role of different staff types within the provision of the service, including how the pharmacist will be involved, including providing clinical supervision of the service.

Select an IT system

Pharmacy owners must use an NHS-assured clinical IT system to make their clinical records and payment claims for the service.

These IT systems  allow pharmacy staff to make a clinical record for the service and the data in the record will then be used by the IT system to populate a claim for payment within the NHSBSA’s MYS platform.

The transfer of data via the API will happen throughout the month, as data is entered into the IT systems. The service provisions will then be available to view in MYS from the 1st of the following month. For example, service provisions in December will be available to view in MYS on 1st January. Pharmacy owners will then need to log into the MYS platform to check that the data matches the details in their IT system, and they will then need to submit their claim for payment.

The full dataset for the Hypertension Case-Finding Advanced service can be found in  Annex F  of the  service specification .

The NHS approved clinical IT system will also send messages containing the patient’s results to their general practice.

The following four IT suppliers have developed their systems to include functionality to support the service, but over time, it is hoped other suppliers will add the service to their systems:

Pharmacy owners providing the service will need to consider which system they want to use and will then need to enter into a contract with that supplier.

Read more about the IT requirements for all CPCF clinical services

Engagement with local GP practices and/or PCN colleagues

Prior to provision of the service, pharmacy owners must engage with local general practices and/or PCN colleagues to make them aware the pharmacy is participating in this service.

Practices may want to refer patients to the pharmacy for blood pressure checks (clinic blood pressure checks or ABPM). Where practices wish to use this facility, pharmacy owners should agree a local process with the practice by which this will work. There are no specific requirements set for this process and it could involve the practice agreeing that a specific list of patients can access the service or a cohort of patients could be specified.

A letter / email template to support pharmacy owners to notify GP practices that the pharmacy will be providing the service is available.

Download the GP letter/email service notification template (Microsoft Word) (22nd November 2023)

A briefing to provide information for general practice teams on the Hypertension Case-Finding Service is available to assist pharmacy owners to engage their local general practice colleagues.

Download the Community Pharmacy England Briefing for general practice teams (22nd November 2023)

Pharmacy owner checklist

Once a pharmacy owner has decided they wish to provide the service, our implementation checklist will guide them through the steps they need to take to prepare to provide the service.

Download the pharmacy owner implementation checklist (22nd November 2023)

Following the publication of the latest service specification, pharmacy owners who are already providing the service can use our existing provider checklist to guide them through the steps they need to take to continue to provide the service.

Download the pharmacy owner checklist (existing providers)  (22nd November 2023)

Withdrawal from the service

If the pharmacy owner wishes to stop providing the Hypertension Case-Finding Service, they must notify NHS England that they are no longer going to provide the service via the MYS platform, giving at least one months’ notice prior to the cessation of the service. The pharmacy owner may be asked for their reason for withdrawal from the service.

Providing the service

Patient eligibility to receive the service

The service specification lists the following inclusion and exclusion criteria for the service:

Inclusion criteria

• Adults who are 40 years old or over, who do not have a current diagnosis of hypertension;
• Patients, by exception, under the age of 40 who request the service because they have a recognised family history of hypertension may be provided the service at the pharmacy staff’s discretion;
• Patients between 35 and 39 years old who are approached about or request the service may be tested at the pharmacy staff’s discretion; and
• Adults, with or without a prior diagnosis of hypertension specified by a general practice for the measurement of blood pressure (clinic and ambulatory blood pressure checks). This process should be agreed locally with general practices.

Exclusion criteria

• People under the age of 40 years old, unless at the discretion of the pharmacy staff or unless they have been specified by a general practice for the measurement of blood pressure; and
• People who have their blood pressure regularly monitored by a healthcare professional, unless the general practice requests the service is provided for the patient. Requests should be sent via a process which is agreed locally with general practices;
• People who require daily blood pressure monitoring for any period of time e.g. 7 day clinic checks as an alternative to ABPM; and
• People with a diagnosis of atrial fibrillation or history of irregular heartbeat.

General practice referrals

If practices want to refer patients who have already been diagnosed with hypertension for blood pressure checks, then pharmacy owners should work with their practices to agree a local process by which this will work; there are no specific requirements set for this process and it could involve the practice agreeing that a specific list of patients can access the service or a cohort of patients could be specified.

General practices will also be able to refer patients requiring ABPM; in this scenario it is recommended that this referral is made electronically to the pharmacy.

Download a GP practice referral template (Microsoft Word) (22nd November 2023)

Download a GP practice referral template (22nd November 2023)

Pharmacy blood pressure service finder tool

The service finder on the NHS website lets patients and healthcare professionals search for a pharmacy that provides blood pressure checks as part of the Hypertension Case-Finding Service. The tool also provides information on who is eligible for the service.

The blood pressure service finder

Promoting the service

Pharmacy owners who will be providing the service can use a poster and, where facilities exist, digital marketing resources to advertise the availability of the service in the pharmacy.

Download the poster

Download the digital marketing resources

Small flyers to use on prescription bags etc. (Microsoft Word) (22nd November 2023)

Template patient leaflet to promote the service (Microsoft Word) (22nd November 2023)

Patient leaflet to promote the service (22nd November 2023)

A patient recruitment guide containing tips on how to successfully recruit patients using some of the insights from pilot sites is available as part of the briefing for pharmacy teams on the service.

Patient advice

To further promote the service and support the provision of healthy lifestyle advice, pharmacy owners may consider the use of the Department of Health and Social Care (DHSC) and other patient support or charity organisations such as the British Heart Foundation to source educational materials to promote healthy behaviours, signpost to other services, and improve understanding about blood pressure.

To download or order resources including leaflets, posters, guides and resource packs for campaigns from the DHSC campaigns web pages the pharmacy will need to register on the DHSC Campaign Resource Centre website.

Register here

Below are links to some examples resources which may be appropriate to the healthy lifestyle advice offered as part of this service:

Prior to provision of the service, verbal consent must be sought from the patient by the pharmacy staff and recorded in the pharmacy’s clinical record for the service. Pharmacy owners also need to ensure that the patient is made aware that the following sharing of information will take place:

• The sharing of information between the pharmacy and the patient’s general practice to allow the recording of the blood pressure reading in their GP practice record;
• The sharing of information about the service with NHS England as part of service monitoring and evaluation; and
• The sharing of information about the service with NHSBSA and NHS England as part of post-payment verification.

The General Pharmaceutical Council’s  Guidance on Consent   provides information on consent for pharmacy staff.

Clinic blood pressure check

The first stage of the service is the provision of a normal blood pressure check (clinic check) in line with NICE guidelines.

A visual guide that can be used to support pharmacy staff providing this stage of the service is available below.

Download the clinic blood pressure guide (PDF)

A high systolic and normal diastolic reading OR a high diastolic and normal systolic reading should be recorded as a high blood pressure reading.  Appropriate action should be taken if either the systolic or the diastolic measurement or both fall outside the normal range.

Where pharmacy staff, other than the pharmacist, have provided the service, the Responsible Pharmacist should be made aware of any patients exhibiting physical symptoms before the patient leaves the pharmacy.

ABPM provision

Where a patient is identified as having high blood pressure (140/90mmHg or higher, but lower than 180/120mmHg) prompt provision of ABPM will be dependent on the availability of an ABPM device. Should the patient decline ABPM through the pharmacy, they should be referred to their general practice or another appropriate local pathway.

A leaflet that can be used to provide patients, relatives or carers with information about ABPM and what is involved is available.

ABPM patient leaflet template (Microsoft Word) (22nd November 2023)

ABPM patient leaflet template (22nd November 2023)

When providing ABPM, pharmacy owners may wish to ask the patient to complete an equipment loan agreement.

Download a template ABPM loan agreement form (Microsoft Word) (22nd November 2023)

During a consultation to fit an ABPM device and in line with the device’s instructions and the training provided:

• Reset the ABPM;
• Fit the ABPM to the patient;
• Explain the functioning of the ABPM device to the patient;
• Confirm that the patient understands that they need to stop any activity and rest when the cuff starts to inflate, and that the ABPM is set to take measurements every 30 minutes during waking hours (for example between 8am and 10pm) A minimum of 14 readings are needed during the person’s usual waking hours to provide an accurate average reading;
• Explain they must not get the ABPM wet therefore, baths and showers should be avoided during the monitoring period; and
• Arrange a follow up appointment to discuss the readings and return the equipment.

The use of 14 readings means the latest time for an appointment to see a patient and fit an ABPM would be 2pm if monitoring is stopping at 10pm.

Should a patient fail to attend a scheduled pharmacy appointment to be fitted with an ABPM device, the pharmacy team should make at least two attempts, on separate occasions, to contact the patient to rearrange the appointment. In the event of a failure to attend, the patient’s GP practice should be provided with the initial clinic blood pressure measurement and notified that the patient failed to attend to be fitted with the ABPM device.

Return of ABPM devices

When the patient attends the ABPM follow up appointment:

• Retrieve the patient’s consultation data from the ABPM device in accordance with the manufacturer’s instructions;
• Record the average daytime blood pressure readings in the consultation record; and
• Based on the average daytime reading, the pharmacy staff should follow the relevant guidance in the service specification on the next steps for the patient. All readings (systolic and diastolic for daytime) and the full ABPM report should be shared with the patient’s general practice.

Failure to attend after ABPM for discussion of readings and equipment return

Where a patient fails to attend a scheduled follow up appointment, the pharmacy team should make attempts to contact the patient to rearrange the appointment and return the equipment. If despite the pharmacy team making several attempts on separate occasions to contact the patient, the patient does not return to receive their ABPM results within five working days, the pharmacy staff should:

• contact the patient’s registered general practice, to provide the initial clinic blood pressure result and notify the practice of the service user’s failure to attend following ABPM; and
• Suspend provision of the Hypertension Case-Finding Service until the ABPM meter is retrieved or a replacement device is available.

Information for patients and referrals

Blood pressure readings.

Blood pressure readings should be discussed with the patient and the appropriate next steps as detailed in the service specification (Annex G) should be completed. Results should be provided to the patient in a format that best suits the patient. The patient may prefer to have their readings written on a printed leaflet, it may be completed electronically by the pharmacy staff and emailed to the patient or the patient may prefer to take a photo of their readings using their phone.

Download a patient leaflet to support provision of readings  (Microsoft Word)

Download a patient leaflet to support provision of readings  (PDF)

Healthy lifestyle advice

In line with the principle of Making Every Contact Count, pharmacy staff should encourage the patient to discuss their lifestyle/behaviours and appropriate lifestyle advice should be provided where applicable. Local initiative and services that may assist the patient should be signposted.

Example resources which may be appropriate to support the patient or raise awareness are detailed in the above patient advice section.

Pharmacy owners should record any advice provided and any signposting in the clinical record. Where a patient is not registered with a GP practice, information should be provided to assist the patient to do this.

Communicating with GP practices

Pharmacy owners must ensure that a notification of the provision of the service is sent to the patient’s general practice on the day of provision or on the following working day. Where possible, this should be sent as a structured message in real-time via the NHS assured IT system. In the absence of an automated digital solution or if there is a temporary problem with the system, this should be sent via NHSmail or hard copy.

Details of when to make a referral based on the blood pressure monitoring outcome are detailed in the  service specification .

Details of the required information to be sent to the patient’s general practice based on the blood pressure reading are outlined in Annex E of the  service specification .

Record keeping and data management

Pharmacy owners must use an NHS approved clinical IT system to make their clinical records and payment claims for the service and to send messages containing the patient’s results to their general practice. The transfer of data to the MYS platform is via an API (Application Programming Interface) to automate payment claims and reporting of the data to the NHSBSA.

The transfer of data via the API will happen throughout the month, as data is entered into the IT systems. The service provisions will then be available to view in MYS from the 1st of the following month. For example, service provisions in December will be available to view in MYS on 1st January.

The information to be submitted via the API can be found in an Annex of the service specification. When submitted to the NHSBSA, this data will be used for post-payment verification and it will also be shared with NHS England to support evaluation of the service.

Clinical records of service provisions should be retained for an appropriate period, but for the purposes of post-payment verification, reimbursement records must be kept for a period of three years after the service takes place to demonstrate service delivery in accordance with the service specification. As pharmacy owners are the data controller, it is for each pharmacy owner to determine what the appropriate length of time is, beyond three years that the clinical records are kept for. Decisions on this matter should be documented in the SOP and should be in line with  Records Management Code of Practice for Health and Social Care .

Working with Primary Care Networks

The Advanced service supports the work that general practices and wider Primary Care Network (PCN) teams are undertaking on CVD prevention and management, under the PCN Directed Enhanced Service which commenced on 1st October 2021.

From that date, PCNs must improve diagnosis of patients with hypertension, in line with  NICE guideline NG136 , by ensuring appropriate follow-up activity is undertaken to confirm or exclude a hypertension diagnosis where a blood pressure of ≥140/90mmHg in a GP practice, or ≥135/85mmHg in a community setting, is recorded.

As part of this, PCNs must work pro-actively with community pharmacies to improve access to blood pressure checks, via the hypertension case finding service.

Best practice guidance for 2023/24 on the Network Contract Directed Enhanced Service for CVD prevention and diagnosis can be found on the NHS England website .

Service Data available on the SHAPE website

Data on community pharmacies providing the service is available on the  SHAPE Place Atlas tool .

Strategic Health Asset Planning and Evaluation (SHAPE) is a web enabled, evidence-based application that informs and supports the strategic planning of services and assets across a whole health economy.

The service data on SHAPE, which is aligned to the Index of Multiple Deprivation profiles, includes the number of patients seen monthly, the monthly change and the cumulative number of patients seen since the launch of the Advanced service in October 2021.

Local Pharmaceutical Committees, commissioners, pharmacy owners, general practice and public health professionals and their teams can use the data to work together to target the populations most at risk of CVD morbidity and mortality, to design and implement services to help identify more people with undiagnosed hypertension and reduce health inequalities.

Access to the SHAPE Place Atlas tool is free to NHS professionals and Local Authority professionals with a role in Public Health or Social Care. Access to the application is by formal registration and licence agreement. Pharmacy owners will need to use their personal NHSmail address to register to use the tool.

Where a non-public sector email address is used to register for access, then a senior public sector manager will be required as a sponsor in order to gain access to SHAPE.

Complete the user registration form

Signposting patients 

The blood pressure service finder on the NHS website lets patients and healthcare professionals search for a pharmacy that provides blood pressure checks as part of the Hypertension Case-Finding Service.

Business continuity – service provision during IT issues

Should a pharmacy owner’s chosen NHS approved clinical IT system fail the following forms may be used to maintain provision of the service. Where the clinical IT system is unavailable due to exceptional circumstances beyond the control of the pharmacy owner, then the record of service provision must be added to the clinical IT system as soon as possible after the clinical IT system becomes available again.

Download a template clinical record form (Microsoft Word) (22nd November 2023)

Download a template clinical record form (PDF) (22nd November 2023)

Download a weekly summary template  (Microsoft Excel)

Download a weekly summary template  (OpenDocument)

Download an urgent, same day referral letter/email template (Microsoft Word) (22nd November 2023)

Download an urgent, same day referral letter/email template (PDF) (22nd November 2023)

Download an appointment within seven days referral letter/email template (Microsoft Word) (22nd November 2023)

Download an appointment within seven days referral letter/email template (PDF) (22nd November 2023)

Download an appointment within three weeks referral letter/email template (Microsoft Word) (22nd November 2023)

Download an appointment within three weeks referral letter/email template (PDF) (22nd November 2023)

Funding and claiming payment

The following fees have been agreed for the service:

• A set-up fee of £440;
• A fee for each clinic check of £15; and
• A fee for each ambulatory monitoring of £45.

In addition, the following  incentive fees across Years 3, 4 and 5 of the CPCF 5-year agreement were agreed. An incentive fee of £1,000 was payable in the first year of reaching the specified ABPM threshold for the service provision, followed by a payment of £400 in subsequent years if the pharmacy reached the specified thresholds for those years. The additional incentive fee period has now ended. 

Pharmacy owners who signed up after 2021/22 had to achieve the ABPM activity thresholds specified for the given financial year and received £1,000 as a first payment. If a pharmacy owner signed up in 2021/22 and failed to do 5 ABPMs, they were able to earn £1000 by doing 15 ABPMs in 2022/23. Followed by a payment of £400 in 2023/24 if the pharmacy reached the threshold of 20 ABPM interventions in that year.

Pharmacy owners who signed up in 2021/22 or 2022/23 but not achieving 5 ABPM interventions in 2021/22 or 15 ABPM interventions in 2022/23 and pharmacy owners who signed up in 2023/24 had to achieve 20 ABPM checks in 2023/24 to receive the £1,000 payment. As the incentive fees were only available for thresholds achieved up to 31st March 2024, no further incentive payments will be made after this period.

These incentive payments are funded separately (i.e. from outside the pharmacy global sum) by NHS England to incentivise case finding in line with the ambition outlined in the NHS Long Term Plan.

To achieve these targets, pharmacy owner needed to first identify people in whom ABPM is indicated, i.e. people with high clinic blood pressure measurements who then accept ABPM with accompanying support and advice.

The incentive fees were to help pharmacy owners to fund the capital cost of purchasing a suitable clinic BP meter and an ABPM.

If clinic blood pressure measurements or ABPM are provided at the request of a general practice, the service fees set out above will be paid to the pharmacy owner.

If a pharmacy owner de-registers from the service within 30 days of registration, they will not qualify for the £440 set-up fee. In this event, if the £440 set-up fee has already been paid to the pharmacy owner, this money will be claimed back.

Claiming payment

Data from the NHS assured IT system will be submitted to the MYS portal via an application programming interface and will be used by the NHSBSA to populate a payment claim within the MYS portal.

The pharmacy owner needs to review this payment claim and then submit it. Claims for payment for this service should be made monthly, via the MYS portal and no later than three months from the claim period for the chargeable activity provided. Claims which relate to work completed more than three months after the claim period in question, will not be paid.

If the pharmacy owner is commissioned to deliver any related services, e.g. the Pharmacy Contraception Service (incorporating BP clinic measurement), the pharmacy owner may not claim twice for the same activity.

Data will only be submitted by the NHS assured IT system for completed service provisions. For example, where a clinic check has been undertaken and an ABPM is required, which will be undertaken in the following month, the data for the complete service provision will be reported once both elements of the service (clinic check and ABPM) have been completed.

The full dataset for the Hypertension Case-Finding Service can be found in Annex F of the service specification .

Frequently Asked Questions

Visit the  Hypertension Case-Finding Service Frequently Asked Questions page  for FAQs on the service requirements.

Pharmacy owners and their teams can watch an on-demand recording of Community Pharmacy England’s January 2024 webinar on the re-launch of the Hypertension Case-Finding Service.

The webinar looked at how to make greater use of the whole pharmacy team and ways to maximise the number of eligible patients taking up ambulatory blood pressure monitoring (ABPM).

During the session, the presenters gave a brief review of the service requirements and the changes to the service from 1st December 2023. Attendees also received practical advice and tips from Nadya Jethwa, owner of Bosworth Pharmacy, and Ruksana Khandoker, pharmacist at Day Lewis Harold Hill Health Centre.

During the webinar, attendees heard directly from the Community Pharmacy England Services Team, Dr Yeyenta Osasu, National Pharmacy Integration Lead at NHS England, and Paula Higginson, Head of Learning Development at the Centre for Pharmacy Postgraduate Education (CPPE).

Watch the Hypertension Case-Finding Service webinar

Download the slides from the webinar

Resources and statistics

Briefing 035/23: Updated guidance on the Hypertension Case-Finding (22nd November 2023)

Briefing 036/23: Briefing for pharmacy teams – the Hypertension Case-Finding Service (22nd November 2023)

Briefing 037/23: The Community Pharmacy Hypertension Case-Finding-Service – A briefing for general practice teams (22nd November 2023)

Pharmacy owner implementation checklist (new providers) (22nd November 2023)

Pharmacy owner checklist (existing providers) (22nd November 2023)

Staff training checklist (April 2024)

GP letter/email service notification template (Microsoft Word) (22nd November 2023)

GP practice referral template (Microsoft Word) (22nd November 2023)

GP practice referral template (PDF) (22nd November 2023)

Service poster

Service digital marketing resources

Patient leaflet to promote the service (Microsoft Word) (22nd November 2023)

Patient leaflet to promote the service   (PDF) (22nd November 2023)

ABPM patient leaflet template (PDF) (22nd November 2023)

ABPM loan agreement form (Microsoft Word) (22nd November 2023)

Patient leaflet to support provision of readings  (Microsoft Word)

Patient leaflet to support provision of readings  (PDF)

To support business continuity provisions in the event of IT issues only

Template clinical record form (Microsoft Word) (22nd November 2023)

Template clinical record form (PDF) (22nd November 2023)

Weekly summary template  (Microsoft Excel)

Weekly summary template  (OpenDocument)

Urgent, same day referral letter/email template (Microsoft Word) (22nd November 2023)

Urgent, same day referral letter/email template (PDF) (22nd November 2023)

Appointment within seven days referral letter/email template (Microsoft Word) (22nd November 2023)

Appointment within seven days referral letter/email template (PDF) (22nd November 2023)

Appointment within three weeks referral letter/email template (Microsoft Word) (22nd November 2023)

Appointment within three weeks referral letter/email template (PDF) (22nd November 2023)

The following links provide further information on Hypertension and related topics.

• Blood Pressure UK
• British and Irish Hypertension Society
• British Heart Foundation
• NHS website
• NICE guideline [NG136] – Hypertension in adults: diagnosis and management
• NICE Clinical Knowledge Summaries

NHSE case study: Rohpharm Pharmacy As part of NHS England’s activity to support the International Society for Hypertension’s  May Measurement Month  campaign, which raises awareness of the risks of high blood pressure, they have published a case study on Rohpharm Pharmacy in Newham, East London who are providing the Hypertension case-finding service.

Community Pharmacy England clinical service statistics dashboard The dashboard presents data on the Hypertension case-finding service (as well as other Advanced services) at three levels (national, LPC and individual pharmacy) for each quarter. The dashboards are based on  the NHS Business Services Authority’s (NHSBSA) Dispensing Contractors’ data.

NHSBSA Dispensing Contractors’ data Data on the Hypertension Case-Finding Service (as well as other Advanced services) can be found by clicking on the ‘Pharmacy and appliance contractor dispensing data’ dropdown tab.

If having read the service specification and the information on this webpage pharmacy owners have outstanding questions regarding the service, they can email them to  [email protected] .

Latest National Pharmacy Services news

Hypertension Case-Finding Service reminder (#1): Maximising the use of my team

This is the first of a series of articles to help pharmacy owners and their…

Reminder: GP Connect: Update Record rollout

GP Connect: Update Record is a new feature that CPCF IT system suppliers are adding…

Revised Schedule of Payments expected in April

The look of your monthly Schedule of Payments (and eSchedules) is changing from April 2024.…

New Pharmacy First materials aimed at GPs

Community Pharmacy England has launched a set of materials – including a video animation and…

Pharmacy First claims and payments

Some pharmacy owners are continuing to identify issues with the Pharmacy First service figures within…

Community Pharmacy Contractual Framework: Negotiations for 2024/25

The start of April 2024 marks the end of the five-year Contractual Framework arrangement which…

Pharmacy technicians to be given greater powers to supply and administer medicines

The Department of Health and Social Care (DHSC) has today announced plans to update legislation…

Hypertension Case-Finding Service: Important reminder on end of ABPM incentive

Community pharmacy owners are reminded, that the incentive fee payable for reaching the year-5 specified…

Flu vac: NHSE publishes 2024/25 service spec

Following discussions with Community Pharmacy England, NHS England has published the service specification for the…

Pharmacy First declaration data issue resolved

The NHS Business Services Authority (NHSBSA) has emailed pharmacy owners today to say that the…

Pharmacy First: Requirement to have an otoscope from 1st April

Pharmacy owners are reminded that from 1st April 2024,  they must have an otoscope available,…

LFD service: New eligible patient groups from 1st April

The Lateral flow device tests supply service for patients potentially eligible for COVID-19 treatments (LFD…

Privacy Overview

• Prospective Student Inquiries [email protected]
• General Inquiries [email protected]
• Job Posting Request
• Building Hours & Maps
• Prospective Students
• Current Students

What's Happening

Student resources, quick links.

• Alumni & Friends

Update Your Information

Academic departments, clinical pharmacy, medicinal chemistry, pharmaceutical sciences, research in clinical pharmacy, research in medicinal chemistry, research in pharmaceutical sciences, research cores and services, biointerfaces institute, michigan drug discovery.

• Michigan Institute for Clinical & Health Research

Translational Oncology Program

• Faculty Publications
• Research Opportunities
• Research Collaborations

UM Pharmacy Professor Research Outreach (PRO)

About the college, message from the dean.

• Dean Search

Accreditation

New cop building, our history, our leadership.

• Our Mission, Vision & Organization

Teaching Excellence Awards

Job openings.

• Diversity, Equity & Inclusion

Department Contact Info

Emergency information.

• COVID-19 Updates

Sexual and Gender-Based Misconduct

• Alternative and Complementary Medicines
• Diagnosis and Health Conditions
• Healthy Choices
• Information for Caregivers
• Medication Information
• Other Resources
• COP Directory

Search form

• Alumni & Friends

Why U-M Pharmacy?

Recruitment events, student blogs, career potential, program overview.

• Information Request Form

PharmD Program

• Experiential Education
• Pharmacy Phamilies
• PharmD Curriculum
• Assessments
• Pharmacy Student Ambassadors
• Pre-Pharmacy Student Organization (PPSO)

PhD in Clinical Pharmacy

Phd in medicinal chemistry, phd in pharmaceutical sciences, ms in integrated pharmaceutical sciences.

• Career Flexibility

BS in Pharmaceutical Sciences

• Program Goals
• Fast Track to PharmD
• Student Services
• Research and Honors Program
• Student Outcomes

Dual Programs

• Dual PharmD and MBA Program
• Dual PharmD and MPH Program
• Dual PharmD and PhD Program

Post-Doc in Clinical Pharmacy

Residency program, ambulatory care enrichment program, research experiences for undergraduates program.

• Eligibility
• Program Schedule
• Application
• Pharmacy Scholars Program
• Frequently Asked Questions
• Income Guidelines

Assignment of Credit Hours

Pharmacy community college connect, postdoctoral collegiate fellows program.

• Expectations of Faculty Mentors
• Faculty Mentor List
• Review & Selection

PharmD Program Admissions

• Application Overview
• PharmD Prerequisites
• Preferred Admission Programs
• Applicant Characteristics

PhD Program Admissions

Ms program admissions, bachelors program admissions, funding your education, financial aid brochure.

• Tuition and Fees
• PharmD Scholarships
• Graduate Support

Student Organizations

• Student News

Course Descriptions

Student affairs.

• Financial Aid & Scholarship
• Advising & Registration
• Career Counseling
• Personal Counseling
• Campus Resources
• Student Affairs Directory

Career Connections

Student handbook, access pharmacy, campus groups, cornerstone learning, outlook in the cloud, rx preceptor, taubman library, wolverine access.

• Prescott & Emeritus Celebration

Alumni Awards

• Alumni News

Board of Governors

• Nomination Form
• Board Member Position Description

Job Opportunities

Submit personal news, meet the advancement team, update your alumni record.

• News & Events
• Previous Faculty Spotlights
• Department Metrics
• Research Laboratories
• CPTS PhD Program
• CPTS Fellowship Program
• Post-Graduate Residency
• REACH Fellowship
• Infectious Diseases Fellowship
• ACE Program
• Vision and Mission
• Department Directory
• Simulated Patient Program
• Biochemical NMR Core
• Clinical Pharmacogenomics Laboratory
• Pharmacokinetic and Mass Spectrometry Core
• Vahlteich Medicinal Chemistry Core

Michigan Institute for Clinical & Health Research

• Previous Seminars
• Newly Awarded
• Available Funding
• Grant Tools "Coming Soon"
• Giving Tuesday
• Faculty News
• Research News
• Annual Report Archive
• Upcoming Events
• Newsletter Archive

Our Mission, Vision & Organization

• COP Organization Chart
• COP Strategic Plan

Diversity, Equity & Inclusion

• Dean's Vision Statement
• DEI Strategic Plan
• Upcoming News & Events
• REU Program
• Education & Training
• McKesson Foundation Health Equity Speaker Series
• Resources & Support
• Concern Reporting
• Emergency FAQs
• Stay Informed!

Case Study: Hypertension Improved by 66% in 3 Months with Pharmacist-Centric Care Model

Keep up to date sign up for our newsletter.

It's really great, you'll like it!

See Past Newsletters

HTN_Blood_Pressure.png

Download Case Study  

Hypertension is a silent, often symptom-free condition affecting an estimated 47% of adults, or nearly 120 million people, in the United States.

Only about a quarter of those patients diagnosed with hypertension have their blood pressure under control (130/80 mm/Hg or less), according to the CDC.2 Uncontrolled blood pressure is a serious risk factor, and it is closely linked to stroke and heart disease, two of the leading causes of death in the United States (U.S.)

With uncontrolled hypertension, there is a risk of death and disability due to cardiovascular disease. This chronic condition can be managed by medication, lifestyle factors such as improved diet and exercise, or a combination of both. Hae Mi Choe , Associate Dean for Pharmacy Innovations and Partnerships at the College of Pharmacy and Chief Population Health Officer for University of Michigan Health, recognized that Pharmacists could play a role in the solution.

Creating a Pharmacist-Centric Care Model

In 1999, Dr. Choe, recognized that to improve the management of chronic conditions like hypertension, prescribed treatments should be paired with patient education, counseling, and follow-up visits to ensure that patients understand the importance of adhering to their care plan.

Knowing that patient education is at the core of a pharmacist’s role, Dr. Choe and her team created a new pharmacist-centric care model to try to improve patients’ control of their blood pressure and test the effectiveness of this approach. In the program they created, the pharmacist:

• Is embedded in the care team and specially trained.
• Provides education and consultation to their patients.
• Follows up with patients to monitor lifestyle changes and the effectiveness of the drugs.
• Adjusts therapeutic regimen to improve patient outcomes in coordination with the physicians.

Program Launch and Expansion of the Hypertension Pharmacist Program (HPP)

• Dr. Choe launched the program in one ambulatory care clinic at East Ann Arbor Health Center in Michigan and continued to expand into all primary care clinics at U-M Health.
• Recognizing that for patients to get to their primary care clinic for counseling and follow-ups to monitor their condition may not be convenient (or possible) on a regular basis. HPP partnered with Meijer, a Michigan-based chain of superstores. Its pharmacists went through special training to provide the same customized consultation by appointment in stores. The partnership expanded to encompass five participating stores that offer 52 consultation appointments per week.

HPP_HTN_Flywheel.png

HPP grew to include all of U-M Health’s 14 primary care clinics. Analysis showed that the program was highly effective.

Outcomes Evaluation and Expansion of HPP by Centers for Disease Control and Prevention (CDC)

In 2023, the Centers for Disease Control and Prevention (CDC), seeking proven patient-centered models of care that help patients better control their hypertension, selected HPP as a potential model to replicate. The CDC’s Division for Heart Disease and Stroke Prevention conducted a thorough evaluation of the program and showed that providing pharmacist-based consultations and follow-up helped participating patients achieve and maintain control of their blood pressure:

In addition, the CDC evaluation showcased that HPP:

• Improved medication management and patients benefited from more frequent adjustments than those not in the program.
• Participants had fewer visits to their primary care physician.

As a result of these findings, the CDC highlighted the HPP as an effective model and published a detailed implementation guide to support and encourage other health systems to replicate the University of Michigan Health approach.

CDC Piloting the Model to Reach Underserved Populations.

Based on the success of HPP, the CDC is replicating and scaling the program to reach underserved patient communities in the southeastern U.S., and sought nominations of healthcare systems serving primarily African American patients. Initially, one will be selected for implementation of the HPP model, with training and partial financial support.

HPP_HTN_Results_Table.png

The program continues to expand based on the demand for services, which include increasing available hours for follow-up at the clinics and community pharmacies. What’s even more exciting is that Dr. Choe is looking to expand community pharmacy partnerships into other disease states based on the positive outcomes with hypertension.

1. Centers for Disease Control and Prevention. Estimated Hypertension Prevalence, Treatment, and Control Among U.S. Adults. Million Hearts: https://millionhearts.hhs.gov/data-reports/hypertension-prevalence .

html, accessed 8 Jan. 2024.

2. centers for disease control and prevention. hypertension cascade: hypertension prevalence, treatment and control estimates among u.s. adults aged 18 years and older applying the criteria from the, american college of cardiology and american heart association’s 2017 hypertension guideline—nhanes 2015–2018. atlanta, ga: u.s. department of health and human services; 2021..

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Review Article
• Published: 01 April 2020

Pharmacist’s role in hypertension management: a review of key randomized controlled trials

• Tyler D. Wagner 1 ,
• Morgan C. Jones 1 ,
• Teresa M. Salgado 1 , 2 &
• Dave L. Dixon   ORCID: orcid.org/0000-0001-7560-9521 1 , 2  

Journal of Human Hypertension volume  34 ,  pages 487–494 ( 2020 ) Cite this article

1437 Accesses

17 Citations

298 Altmetric

Metrics details

• Health care
• Hypertension

Hypertension (HTN) is a leading cause of death and disability throughout the world. Yet, despite widely available treatment options, blood pressure (BP) control rates have remained relatively stagnant. One approach to address this issue is through collaborative care models, particularly those employing pharmacists. Numerous randomized controlled trials (RCT) have demonstrated the effectiveness of pharmacist interventions to improve BP control across primary care, community-based, and telemedicine models. A meta-analysis of 39 RCTs has demonstrated that pharmacist interventions significantly reduce both systolic and diastolic BP compared with controls across diverse patient populations. Pharmacists can contribute to HTN management in a variety of ways, including assisting with out-of-office monitoring, providing education, identifying and resolving nonadherence, and titrating antihypertensive therapy to achieve BP control. In this review, we discuss key trials conducted in recent years that support the role of pharmacists in HTN management and provide guidance on practical considerations for working collaboratively with pharmacists to improve BP control.

This is a preview of subscription content, access via your institution

Access options

Subscribe to this journal

Receive 12 digital issues and online access to articles

111,21 € per year

only 9,27 € per issue

Buy this article

• Purchase on Springer Link
• Instant access to full article PDF

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

Remote follow-up by pharmacists for blood pressure control in patients with hypertension: a systematic review and a meta-analysis of randomized controlled trials

Effectiveness of a patient-centered medical home model of primary care versus standard care on blood pressure outcomes among hypertensive patients

The India Hypertension Control Initiative–early outcomes in 26 districts across five states of India, 2018–2020

Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365:217–23.

Woolf SH, Schoomaker H. Life expectancy and mortality rates in the United States, 1959-2017. JAMA. 2019;322:1996–2016.

Article   Google Scholar  

Muntner P, Carey RM, Gidding S, Jones DW, Taler SJ, Wright JT, et al. Potential U.S. population impact of the 2017 ACC/AHA high blood pressure guideline. J Am Coll Cardiol. 2018;71:109–18.

Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. JACC 2018;71:e127–248.

Mills KT, Obst KM, Shen W, Molina S, Zhang HJ, He H, et al. Comparative effectiveness of implementation strategies for blood pressure control in hypertensive patients: a systematic review and meta-analysis. Ann Intern Med. 2018;168:110–20.

Greer N, Bolduc J, Geurkink E, Rector T, Olson K, Koeller E, et al. Pharmacist-led chronic disease management: a systematic review of effectiveness and harms compared with usual care. Ann Intern Med. 2016;165:30–40.

Santschi V, Chiolero A, Colosimo AL, Platt RW, Taffé P, Burnier M, et al. Improving blood pressure control through pharmacist interventions: a meta-analysis of randomized controlled trials. J Am Heart Assoc. 2014;3:e000718.

Rui P, Okeyode T. National Ambulatory Medical Care Survey: 2016 National Summary Tables; 2016. https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdf .

Association of American Medical Colleges. The 2019 update: the complexities of physician supply and demand: projections from 2017 to 2032; 2019. https://www.aamc.org/data-reports/workforce/data/2019-update-complexities-physician-supply-and-demand-projections-2017-2032 .

Carter BL, Coffey CS, Ardery G, Uribe L, Ecklund D, James P, et al. Cluster-randomized trial of a physician/pharmacist collaborative model to improve blood pressure control. Circ Cardiovasc Qual Outcomes. 2015;8:235–43.

Drug Store News. Rx impact: a drug store news special report; 2016. p. 23. https://www.nacds.org/pdfs/DSN_RxIMPACT2016.pdf .

Cheema E, Sutcliffe P, Singer DRJ. The impact of interventions by pharmacists in community pharmacies on control of hypertension: a systematic review and meta-analysis of randomized controlled trials. Br J Clin Pharmacol. 2014;78:1238–47.

Article   CAS   Google Scholar  

Tsuyuki RT, Al Hamarneh YN, Jones CA, Hemmelgarn BR. The effectiveness of pharmacist interventions on cardiovascular risk: the multicenter randomized controlled RxEACH trial. J Am Coll Cardiol. 2016;67:2846–54.

Parker LJ, Hunte H, Ohmit A, Thorpe RJJ. Factors associated with black men’s preference for health information. Health Promot Pract. 2017;18:119–26.

Victor RG, Ravenell JE, Freeman A, Leonard D, Bhat DG, Shafiq M, et al. Effectiveness of a barber-based intervention for improving hypertension control in black men: the BARBER-1 study: a cluster randomized trial. Arch Intern Med. 2011;171:342–50.

Victor RG, Lynch K, Li N, Blyler C, Muhammad E, Handler J, et al. A cluster-randomized trial of blood-pressure reduction in black barbershops. N Engl J Med. 2018;378:1291–301.

Victor RG, Blyler CA, Li N, Lynch K, Moy NB, Rashid M, et al. Sustainability of blood pressure reduction in black barbershops. Circulation. 2019;139:10–9.

Poulson LK, Nissen L, Coombes I. Pharmaceutical review using telemedicine-a before and after feasibility study. J Telemed Telecare. 2010;16:95–9.

Margolis KL, Asche SE, Bergdall AR, Dehmer SP, Groen SE, Kadrmas HM, et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control a cluster randomized clinical trial. JAMA. 2013;310:46–56.

Ashmann J, Rui P, Schappert S. Age differences in visits to office-based physicians by adults with hypertension: United States, 2013. NCHS Data Brief. 2016;263:1–7.

Littauer SL, Dixon DL, Sisson EM, Salgado TM. Pharmacists providing care in the outpatient setting through telemedicine models: a narrative review. Pharm Pract. 2017;15:1–8.

Google Scholar  

Green BB, Cook AJ, Ralston JD, Fishman PA, Catz SL, Carlson J, et al. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. JAMA. 2008;299:2857–67.

Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288:2469–75.

Dehmer SP, Maciosek MV, Trower NK, Asche SE, Bergdall AR, Nyboer RA, et al. Economic evaluation of the home blood pressure telemonitoring and pharmacist case management to control hypertension (Hyperlink) trial. J Am Coll Clin Pharm. 2018;1:21–30.

Margolis KL, Asche SE, Dehmer SP, Bergdall AR, Green BB, Sperl-Hillen JM, et al. Long-term outcomes of the effects of home blood pressure telemonitoring and pharmacist management on blood pressure among adults with uncontrolled hypertension: follow-up of a cluster randomized clinical trial. JAMA Netw Open. 2018;1:e181617.

Margolis KL, Crain AL, Bergdall AR, Beran M, Anderson JP, Solberg LI, et al. Design of a pragmatic cluster-randomized trial comparing telehealth care and best practice clinic-based care for uncontrolled high blood pressure. Contemp Clin Trials. 2020:105939. https://doi.org/10.1016/j.cct.2020.105939 (in press).

Centers for Disease Control and Prevention. Using the pharmacists’ patient care process to manage high blood pressure: a resource guide for pharmacists acknowledgments. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2016.

Dunn SP, Birtcher KK, Beavers CJ, Baker WL, Brouse SD, Page RL, et al. The role of the clinical pharmacist in the care of patients with cardiovascular disease. J Am Coll Cardiol. 2015;66:2129–39.

Saseen JJ, Ripley TL, Bondi D, Burke JM, Cohen LJ, McBane S, et al. ACCP clinical pharmacist competencies. Pharmacotherapy. 2017;37:630–6.

American Hypertension Specialist Certification Program (AHSCP). Certified hypertension clinician (CHC); 2020. http://www.ahscp.org/certified-hypertension-clinician/ .

Board of Pharmacy Specialties. BPS specialties; 2020. http://bpsweb.org/bps-specialties/ .

McBane SE, Dopp AL, Abe A, Benavides S, Chester EA, Dixon DL, et al. Collaborative drug therapy management and comprehensive medication management—2015. Pharmacotherapy. 2015;35:e39–50.

Kliethermes MA. Understanding health care billing basics. Pharm Today. 2017;23:57–68.

Dixon DL, Salgado TM, Caldas LM, Van Tassell BW, Sisson EM. The 2017 American College of Cardiology/American Heart Association hypertension guideline and opportunities for community pharmacists. J Am Pharm Assoc. 2018;58:382–6.

Download references

This material is based upon work supported by the Centers for Disease Control and Prevention under Grant No. DP006620.

Author information

Authors and affiliations.

Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA

Tyler D. Wagner, Morgan C. Jones, Teresa M. Salgado & Dave L. Dixon

Center for Pharmacy Practice Innovation, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA

Teresa M. Salgado & Dave L. Dixon

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Dave L. Dixon .

Ethics declarations

Conflict of interest.

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Cite this article.

Wagner, T.D., Jones, M.C., Salgado, T.M. et al. Pharmacist’s role in hypertension management: a review of key randomized controlled trials. J Hum Hypertens 34 , 487–494 (2020). https://doi.org/10.1038/s41371-020-0331-7

Download citation

Received : 09 December 2019

Revised : 12 March 2020

Accepted : 13 March 2020

Published : 01 April 2020

Issue Date : July 2020

DOI : https://doi.org/10.1038/s41371-020-0331-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Hypertension: pharmacological management

Shutterstock.com

After reading this article, you should be able to: 

• Understand the diagnostic criteria for hypertension and blood pressure (BP) targets; 
• Know the most used medications to treat hypertension and their main contra-indications, adverse effects and monitoring requirements; 
• Support patients to manage their hypertension, including measuring their BP at home ;
• Consider the practical aspects when conducting remote consultations for hypertension.

Introduction 

High systolic blood pressure (BP) is the most prevalent modifiable cardiovascular (CV) risk factor and a leading cause of death worldwide, accounting for 10.8 million deaths in 2019 ​[1]​ . Hypertension is a common condition within the UK; in 2017, it was suggested that 11.8 million adults had a diagnosis, which equates to one in four adults ​[2]​ . Lowering systolic BP by 20mmHg (or diastolic BP by 10mmHg) halves the risk of dying from stroke, ischaemic heart disease and other vascular causes ​[3]​ . Additional information can be found in ‘ Assessment and prevention of cardiovascular disease ’. The systolic pressure refers to the pressure the blood exerts on the walls of the arteries when the heart is pumping blood around the body; it is the higher of the two numbers. The diastolic pressure is the smaller of the two numbers and refers to the pressure in the patient’s arteries when the heart is relaxed. A normal BP is typically in the range of 90/60mmHg to 120/80mmHg ​[4]​ . Ensuring good control of BP in general practice, especially when using their prescribing qualification, is an excellent opportunity for pharmacists to improve patient care and save lives. 

This article will provide an overview of the pharmacological management of hypertension and the role of the pharmacist prescriber in general practice. For information on the range of non-pharmacological interventions that can be adopted by patients, please see ‘ Managing hypertension: the role of diet and exercise ’.

Diagnosis 

In most people, hypertension is asymptomatic, hence the importance of regular BP checks. Patients with an optimal BP <120/80mmHg should have their BP checked in clinic at least every five years; if their BP is in the range of 120–129/80–84mmHg it should be repeated at least every three years; for those with high-normal BP readings, i.e. 130–139/85–89mmHg, their BP should be checked at least annually. This patient cohort may benefit from ambulatory blood pressure (ABPM) monitoring to assess for masked hypertension (when clinic readings are lower than those measured at home). A clinic value of systolic BP >140mmHg or diastolic BP >90mmHg must be followed up with ABPM to confirm a diagnosis of hypertension ​[5]​ . If clinic BP is more than 180/120mmHg, it may require specialist same-day referral or immediate treatment with antihypertensives, rather than waiting for ABPM results ​[6]​ . For full details on diagnosing hypertension, please refer to the National Institute for Health and Care Excellence (NICE) guidelines ​[6]​ .

Pharmacists may be involved in the fitting and interpretation of ABPM. This involves fitting the patient with a BP monitor and cuff that automatically inflates — for example, every half hour during the day and less often (e.g. every hour) at night. A mean daytime figure of ≥135/85mmHg confirms a diagnosis of hypertension. An average of at least 14 daytime measurements should be taken during the patient’s usual waking hours to confirm the diagnosis of hypertension ​[6]​ .

NICE recommends home blood pressure monitoring (HBPM) if ABPM is not tolerated ​[6]​ . HBPM is when the patient measures their own blood pressure, this can be carried out on a device supplied by the GP practice or on a patient’s own device, provided it is approved for use in the UK. Patients wishing to purchase their own monitor can be directed to the British Heart Foundation online shop ​[7]​ . ABPM has the advantage over HBPM in that more readings will be collected, and at random, so patients cannot decide when their readings are done (e.g. during times when they feel very relaxed) ​[2]​ . Having access to nocturnal BP readings also allows identification of patients whose BP does not decrease at night. During sleep, it is normal for both systolic and diastolic BP to fall by about 10–20% of the daytime values ​[8]​ . If BP does not fall by 10% or more at night, patients are termed ‘non-dippers’ and are at increased cardiovascular risk ​[8]​ . 

A patient undergoing HBPM should be advised: 

• For each BP recording, two consecutive measurements should be taken, at least one minute apart and with the person seated;  
• BP should be recorded twice daily, ideally in the morning and evening ;  
• BP recording should be continued for at least four days, but ideally for seven days ​[6]​ . 

The measurements taken on the first day should be discarded and the average value of all the remaining measurements should be used to confirm a diagnosis of hypertension ​[6]​ . 

If ABPM or HBPM reveals that the patient’s mean daytime systolic blood pressure is ≥135mmHg and/or mean daytime diastolic BP is ≥85mmHg, a diagnosis of hypertension is made. NICE also subclassifies the diagnosis, according to stage, as shown in Table 1 ​[6]​ . This will not affect treatment choice, but later stages are likely to require more aggressive treatment to bring BP to target.  

Pharmacists working in general practice can check that the following tests, which are recommended by NICE, have been completed when a patient is diagnosed with hypertension. These are conducted to detect target organ damage (e.g. left ventricular hypertrophy, renal disease, hypertensive retinopathy) ​[6]​ . 

• Blood tests: Plasma glycated haemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration (those with chronic kidney disease [CKD] should have their BP well controlled), liver function and lipids; 
• CVD risk calculated :  A pharmacist can estimate QRISK3 by using various risk factors that have been recorded within the patient’s clinical records (e.g. BP, lipids, age, smoking status, ethnicity, family history of ischaemic heart disease and the presence of other conditions that increase CVD risk, such as CKD, atrial fibrillation, diabetes and rheumatoid arthritis). Those with an estimated CVD risk of ≥10% should have a formal QRISK3 calculated and offered a statin (atorvastatin 20mg daily) if ≥10% ​[9]​ ; 
• Urinalysis: Test for haematuria and proteinuria using a reagent stick. Send urine for albumin:creatinine ratio (ACR) to detect elevations in albuminuria, which is an early indicator of renal damage. Reduction in microalbuminuria has been shown to delay the progression of diabetic and non-diabetic CKD ​[10]​ ;  
• Fundoscopy: Examination of fundi may detect hypertensive retinopathy; however, if the patient attends an optometrist for regular eye checks, most optometrists perform retinal photography as part of the routine screening, making fundoscopy in these patients less clinically useful ​[6,11]​ ; 
• 12-lead electrocardiogram: This is useful for detecting left ventricular hypertrophy, previous myocardiaI infarction or atrial fibrillation ​[5]​ . For more information on the basic principles of the electrocardiogram and how to recognise common abnormalities, see ‘ Interpretation of electrocardiograms ’. 

Pharmacists should also ensure that a sitting and standing check of BP is completed in the following patients: 

• Those with type 2 diabetes mellitus; 
• Those with symptoms of postural hypotension (e.g. falls or postural dizziness);
• Those aged 80 years and over ​[6]​ .

When to start treatment for hypertension 

NICE guidelines provide clinicians with a useful decision aid to support discussions with patients regarding when is the most appropriate time to commence pharmacotherapy ​[6]​ . Decisions to commence pharmacotherapy must be patient-centred and aligned to the key principles of medicines optimisation ​[12]​ . All patients should be able to understand the risks and benefits associated with the treatment recommendations offered to them, allowing them to make an informed decision about ongoing management.  

NICE recommends that pharmacotherapy is commenced in conjunction with lifestyle modification in all patients with persistent stage 2 hypertension (clinic blood pressure ≥160/100mmHg), irrespective of age; more information on the role of lifestyle modifications can be found here . It will be necessary to use and apply clinical judgment to treatment decisions in patients of any age with documented frailty. Documented discussions regarding the commencement of therapy should occur with patients in whom persistent stage one hypertension is noted, who have one or more of the following: 

• Target organ damage;
• Established CVD; 
• Renal disease; 
• Diabetes; 
• QRISK3 score of greater than 10% ​[6]​ . 

Treatment choice and stepwise approach 

NICE guidelines take a stepwise approach to pharmacological management, with choices made that account for both the patient’s age and ethnicity ​[6]​ . This stepwise approach is outlined in Figure 1.  

Table 2 provides an overview of the medicine classes used in the management of hypertension as shown in steps one to three of the NICE algorithm ​[13–17]​ (see Figure 1). Note that treatment choice should be based on comorbidities and any contraindications or cautions relevant to the individual patient. 

Please note, this article discusses some of the main points to consider when prescribing antihypertensive drugs. For full details on these medicines, consult the latest edition of the British National Formulary ( BNF) or summary of product characteristics within the Electronic Medicines Compendium.  

Management in specific patient groups  

First-line choice of antihypertensive agent will depend on any patient comorbidities. For example, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are first-line choices for patients with diabetes and those with CKD, in whom good BP control is particularly important, owing to their increased CVD risk ​[6]​ . Note from Figure 1 that first-line treatment for patients who are of black African or African-Caribbean family ethnicity is a calcium channel blocker (CCB), irrespective of patient age ​[18]​ . This is owing to the influence of genetics — within this population, lower levels of renin result in a lesser response to medicines, which exert their pharmacological influence on BP through the renin-angiotensin system, such as in the use of ACEIs, ARBs and betablockers. If further treatment is required in this patient group, an ARB is preferable over an ACEI ​[6]​ . The choice of first-line antihypertensive agent will also be influenced by any compelling indications or contra-indications that an individual patient may have. For example, in patients with peripheral oedema or heart failure, or at risk of developing heart failure, a thiazide (or thiazide-like) diuretic is preferred to a CCB. Beta-blockers and ACEIs/ARBs may be first-line agents in patients who also have heart failure or in those who have had a myocardial infarction ​[19,20]​ . 

Considerations for treatment intensification  

Only about a quarter of all patients with hypertension will be well controlled on monotherapy ​[21]​ . Many patients are likely to require two or more antihypertensive drugs to reach target. It is often beneficial to advise patients of this from the outset of treatment to avoid them feeling demotivated if control is not achieved with the first medication ​[22]​ . Please refer to the BNF for initiation and maintenance doses of antihypertensive agents ​[23]​ . The current thiazide-like diuretic of choice is indapamide, but it is important to note that for patients established on and stable with bendroflumethiazide 2.5mg once daily, there is no need to change therapy. There is also no additional anti-hypertensive benefit derived from bendroflumethiazide 5mg once daily; increasing to this dose predisposes the patient to an increased risk of side effects. Although the BNF states the dose range for lisinopril is 10mg to 80mg daily, there is little further antihypertensive benefit from increasing beyond 20mg daily ​[24]​ .   

It should be noted that the adverse effects of dihydropyridine CCBs are dose related, with a much higher rate of ankle swelling on amlodipine 10mg than amlodipine 5mg ​[25]​ .   

These factors need to be considered when deciding whether to increase the antihypertensive dose or add in an additional antihypertensive agent. In practice, combining two or more drugs allows lower doses to be used, which is likely to be better tolerated than titrating one antihypertensive drug up to maximum dose ​[26]​ .   

Blood pressure targets 

Once established on therapy, patients must be aware of their own BP target. These targets should be based on the recommendations within NICE guidelines, while also considering patients’ underlying comorbidities, age and frailty status (these are summarised in Tables 3 and 4) ​[6]​ . The general target for patients aged under 80 years (including those with diabetes) is clinic BP <140/90mmHg for both primary and secondary prevention. For those aged 80 years or more, this target is <150/90mmHg. Note that some populations have lower targets than this; for example, those with CKD and proteinuria (ACR >70 mg/mmol), clinic BP target is <130/90mmHg ​[6]​ . Clinic BP should be used to monitor the response to treatment or lifestyle modifications. ABPM/HBPM can be used if clinic BP remains high following treatment or if ‘white coat’ hypertension (i.e. when BP readings are higher in clinical settings than when at home) is suspected. When the patient has achieved their target BP, they should be reviewed, no less frequently than annually. 

Supporting patients to measure blood pressure at home and manage their hypertension 

NHS England supports patients who wish to monitor their condition at home through the ‘bloodpressure@home’ scheme ​[7]​ . This scheme emphasises the importance of using a validated BP monitor and has involved the distribution of more than 220,000 BP monitors (since October 2020) around England, so that patients can record their BP and send their readings to their GP practice to review. The British Heart Foundation has a useful resource for patients on measuring BP at home, including where to buy validated monitors, how to measure BP, and lifestyle measures to reduce CVD risk ​[27]​ . Additional resources for both healthcare professionals and patients on home BP monitoring can be accessed on the British and Irish Hypertension Society’s website ​[28]​ .   

Impact of COVID-19 and remote monitoring 

The COVID-19 pandemic resulted in an unprecedented suspension to normal pathways of care. Dale et al . noted a decreasing trend in CVD medicines dispensed over the course of 2020/2021, suggesting a reduction in the active management of CVD in the UK population ​[29]​ . An estimated 491,306 fewer individuals commenced antihypertensive medication across England, Scotland and Wales during this time frame. The consequences of this are potentially huge, with an estimated additional 13,662 additional CVD events over the course of a person’s lifespan, should individuals remain untreated for hypertension. Detection and treatment levels are improving, but to date are not yet back to pre-pandemic levels ​[29]​ .

During the pandemic, face-to-face appointments were quickly replaced with a ‘new normal’ of remote consultations either via the telephone or through video consultations, with both clinicians and patients having to adapt to this new approach ​[30]​ . Remote consulting has been part of the pharmacists’ skillset for many years, with advantages noted for patients and clinicians. Many consultations do not require a face-to-face appointment and conducting consultations remotely can be more convenient and time-efficient for both patients and healthcare professionals. When conducting hypertension reviews virtually, pharmacists should adopt the CONSULT checklist, which embodies the importance of a person-centred approach and shared decision making ​[31]​ . It is essential that the pharmacist conducting the remote consultation acknowledges that this may not be the best approach for all patients. Judgements must be made about the digital health literacy of the patient, their ability to use the digital platform and the capability of the patient to monitor their condition safely at home. Practices should ideally have clinically-validated BP monitors to loan to patients to aid in the accurate home monitoring of BP if ABPM monitoring is not suitable for them to assist with diagnosis.  

Given the vast body of evidence supporting the benefits of antihypertensive treatment, pharmacist prescribers are in an excellent position to use their knowledge and skills around medicines to reduce morbidity and improve patient care. A summary box of the main counselling points to support patients with hypertension is given below. 

Box: Summary

Patient counselling and support.

• Patients should be educated on the consequences of untreated hypertension (e.g. increased risk of heart failure, cardiovascular disease, chronic kidney disease, peripheral artery disease, vascular dementia, retinopathy);
• Ensure patients understand the lifestyle modifications (dietary and exercise) they can undertake to reduce their blood pressure (BP) and generally improve their overall health;
• Patients should ‘know their numbers’ i.e. their latest BP reading and what their BP target is based on their age and underlying comorbidities;
• Counsel patients on the dose, frequency and anticipated adverse effects of their prescribed medications and the importance of adherence. Counselling should cover any pertinent points related to their medicines, such as the best time of day to take them and any important food/drink interactions;
• Ensure patients are aware of any signs and symptoms that warrant return to the prescriber for review (e.g. dizziness or severe ankle swelling);
• Advise patients on the frequency of intended monitoring to ensure hypertension is controlled to target and they are not experiencing unwanted adverse effects;
• Advise patients on the benefits of home monitoring, and the importance of measuring BP properly, using a validated BP monitor;
• Consider providing written patient information and refer patients to the NHS and British Heart foundation resources ​[7,27]​ .

Points to consider when prescribing for hypertensive patients

• If involved in the diagnosis of hypertension, ensure all patients have had the recommended baseline monitoring and tests done;
• Provide appropriate lifestyle advice and encourage even small positive changes to diet and exercise;
• Before choosing an antihypertensive agent for a patient, carefully consider its contraindications, compelling indications and expected adverse effects;
• Prescribe medicines that have a good evidence base for hypertension. These tend to be the medicines listed in local formularies;
• Prescribe antihypertensives that can be taken once daily, where possible;
• Ensure that doses are appropriate for the patient’s level of renal function;
• Ensure that medicines have had sufficient time to achieve their antihypertensive effect before increasing the dose or adding another antihypertensive. Most medicines need at least four weeks to exert their effect;
• Consider the patient’s eligibility for a statin i.e. all secondary prevention patients and any primary prevention patients whose CVD risk is ≥10% over the next ten years (using QRISK3);
• Ensure that systems are in place to facilitate regular review of patients and that they are called for BP checks and the required blood monitoring tests at the appropriate time;
• Support patients as per summary above on counselling and support.

Disclosures

Neither author has any affiliation or financial involvement with any drug industries who produce antihypertensive medications. Briegeen Girvin has written review articles and research articles on hypertension previously, including for Prescriber journal. 

• This article was amended on 10 January 2024 to correct an error in Figure 1
• 1 Murray CJL, Aravkin AY, Zheng P, et al. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020;396:1223–49. https://doi.org/10.1016/s0140-6736(20)30752-2
• 2 Hypertension: How common is it? National Institute for Health and Care Excellence. 2023. https://cks.nice.org.uk/topics/hypertension/background-information/prevalence/ (accessed December 2023)
• 3 Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. The Lancet. 2002;360:1903–13. https://doi.org/10.1016/s0140-6736(02)11911-8
• 4 High blood pressure. British Heart Foundation. https://www.bhf.org.uk/informationsupport/risk-factors/high-blood-pressure (accessed December 2023)
• 5 Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal. 2018;39:3021–104. https://doi.org/10.1093/eurheartj/ehy339
• 6 Hypertension in adults: diagnosis and management. National Institute for Health and Care Excellence. 2019. https://www.nice.org.uk/guidance/ng136 (accessed December 2023)
• 7 Home blood pressure monitoring. NHS England. https://www.england.nhs.uk/ourwork/clinical-policy/cvd/home-blood-pressure-monitoring (accessed December 2023)
• 8 Mahabala C, Kamath P, Bhaskaran U, et al. Antihypertensive therapy: nocturnal dippers and nondippers. Do we treat them differently? VHRM. 2013;125. https://doi.org/10.2147/vhrm.s33515
• 9 Cardiovascular disease: risk assessment and reduction, including lipid modification. National Institute for Health and Care Excellence. 2023. https://www.nice.org.uk/guidance/cg181 (accessed December 2023)
• 10 Thomopoulos C, Parati G, Zanchetti A. Effects of blood-pressure-lowering treatment on outcome incidence. 12. Effects in individuals with high-normal and normal blood pressure. Journal of Hypertension. 2017;35:2150–60. https://doi.org/10.1097/hjh.0000000000001547
• 11 How your eyes could help diagnose high blood pressure. University of Hertfordshire. 2022. https://www.herts.ac.uk/about-us/news-and-events/news/2022/how-your-eyes-could-help-diagnose-high-blood-pressure (accessed December 2023)
• 12 Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. National Institute for Health and Care Excellence. 2015. https://www.nice.org.uk/guidance/ng5 (accessed December 2023)
• 13 Treatment summaries: Antihypertensive drugs. BNF. https://bnf.nice.org.uk/treatment-summaries/antihypertensive-drugs/ (accessed December 2023)
• 14 Treatment summaries: Calcium treatment blockers. BNF. https://bnf.nice.org.uk/treatment-summaries/calcium-channel-blockers/ (accessed December 2023)
• 15 Suggestions for Drug Monitoring in Adults in Primary Care. Specialist Pharmacy Service. https://www.sps.nhs.uk/home/tools/drug-monitoring (accessed December 2023)
• 16 Staessen JA, Thijs L, Fagard RH, et al. Calcium Channel Blockade and Cardiovascular Prognosis in the European Trial on Isolated Systolic Hypertension. Hypertension. 1998;32:410–6. https://doi.org/10.1161/01.hyp.32.3.410
• 17 Treatment summaries: Hypertension. BNF. https://bnf.nice.org.uk/treatment-summaries/hypertension/ (accessed December 2023)
• 18 Lip GY. Hypertension and ethnicity – a perspective An article from the e-journal of the ESC Council for Cardiology Practice. European Society of Cardiology. 2004. https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-3/Hypertension-and-ethnicity-a-perspective-Title-Hypertension-and-ethnicity (accessed December 2023)
• 19 Health Topics – Heart Failure. National Institute for Health and Care Excellence. https://cks.nice.org.uk/topics/heart-failure-chronic/ (accessed December 2023)
• 20 Health Topics MI-Secondary prevention. National Institute for Health and Care Excellence. https://cks.nice.org.uk/topics/mi-secondary-prevention/ (accessed December 2023)
• 21 Gradman A. Drug combinations. Hypertension Primer: The Essentials of High Blood Pressure: Basic Science, Population Science, and Clinical Management . Lippincott Williams & Williams 2003:408–11. https://www.wolterskluwer.com/en/solutions/ovid/hypertension-primer-the-essentials-of-high-blood-pressure-basic-science-population-science-and-clinical-management-4196 (accessed December 2023)
• 22 High blood pressure – hypertension. NHS. 2023. https://www.nhs.uk/conditions/high-blood-pressure-hypertension/treatment (accessed December 2023)
• 23 British National Formulary. British National Formulary. https://bnf.nice.org.uk/ (accessed December 2023)
• 24 Heran BS, Wong MM, Heran IK, et al. Blood pressure lowering efficacy of angiotensin converting enzyme (ACE) inhibitors for primary hypertension. Cochrane Database of Systematic Reviews. 2008. https://doi.org/10.1002/14651858.cd003823.pub2
• 25 Andrésdóttir MB, van Hamersvelt HW, van Helden MJ, et al. Ankle Edema Formation during Treatment with the Calcium Channel Blockers Lacidipine and Amlodipine: A Single-centre Study. Journal of Cardiovascular Pharmacology. 2000;35:S25–30. https://doi.org/10.1097/00005344-200000001-00005
• 26 Johnston G. Fundamentals of cardiovascular pharmacology . Wiley-Blackwell 1999.
• 27 How to choose a blood pressure monitor and measure your blood pressure at home. British Heart Foundation. https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/tests/blood-pressure-measuring-at-home (accessed December 2023)
• 28 Home Blood Pressure Measurement. British Hypertension Society. https://bihsoc.org/resources/bp-measurement/hbpm/ (accessed December 2023)
• 29 Dale CE, Takhar R, Carragher R, et al. The impact of the COVID-19 pandemic on cardiovascular disease prevention and management. Nat Med. 2023;29:219–25. https://doi.org/10.1038/s41591-022-02158-7
• 30 Nozato Y, Yamamoto K, Rakugi H. Hypertension management before and under the COVID-19 pandemic: lessons and future directions. Hypertens Res. 2023;46:1471–7. https://doi.org/10.1038/s41440-023-01253-7
• 31 Remote consultations: how pharmacy teams can practise them successfully. Pharmaceutical Journal. 2020. https://doi.org/10.1211/pj.2020.20208102

Please check in “Treatment choice and stepwise approach” section: Under BP targets for Aged >= 80years, the article states Clinic BP < 50/90 mm Hg. This should read < 150/90.

Hi Gillian, Thank you for raising this. We have amended the figure. Best wishes, Sophie, senior subeditor

  Cancel reply

You must be logged in to post a comment.

You might also be interested in…

Pharmacists can provide drug treatment for hypertension, WHO guideline says

Reducing systolic blood pressure to below NICE target could cut heart attacks and CVD deaths, study concludes

Majority of patients being treated for hypertension do not have blood pressure control

• Introduction
• Conclusions
• Article Information

Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); BP, blood pressure; CV, cardiovascular; HDL, high-density lipoprotein; RCT, randomized controlled trial.

Abbreviation: QALY, quality-adjusted life year.

eTable 1. Assumed Patient Characteristics for Pharmacist Hypertension Intervention, Based on Observed Population in Tsuyuki et al 10 Clinical Trial

eTable 2. Model US Cost Inputs

eFigure 1. Association Between Cumulative Cost Savings and QALY Benefit Across a Range of Hypothetical SBP Reductions Associated With the Pharmacist Intervention

Data Sharing Statement

See More About

Sign up for emails based on your interests, select your interests.

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing

Get the latest research based on your areas of interest.

Others also liked.

• Download PDF
• X Facebook More LinkedIn

Dixon DL , Johnston K , Patterson J , Marra CA , Tsuyuki RT. Cost-Effectiveness of Pharmacist Prescribing for Managing Hypertension in the United States. JAMA Netw Open. 2023;6(11):e2341408. doi:10.1001/jamanetworkopen.2023.41408

Manage citations:

© 2024

• Permissions

Cost-Effectiveness of Pharmacist Prescribing for Managing Hypertension in the United States

• 1 Department of Pharmacotherapy and Outcomes Science, Center for Pharmacy Practice Innovation, Virginia Commonwealth University School of Pharmacy, Richmond
• 2 Broadstreet Health Economics and Outcomes Research, Vancouver, British Columbia, Canada
• 3 School of Pharmacy, University of Otago, Dunedin, New Zealand
• 4 Department of Medicine (Cardiology), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada

Question   What would be the cost-effectiveness of implementing a pharmacist-prescribing intervention to improve blood pressure control in the United States?

Findings   In this simulated cost-effectiveness analysis of a 5-state Markov model, 50% uptake of a pharmacist-prescribing intervention to improve blood pressure control was associated with a $1.137 trillion in cost savings and could save an estimated 30.2 million life years over 30 years.

Meaning   These findings suggest that pharmacist-prescribing interventions to improve blood pressure control would provide high economic value compared with usual care.

Importance   Pharmacist-led interventions can significantly improve blood pressure (BP) control. The long-term cost-effectiveness of pharmacist-prescribing interventions implemented on a large scale in the US remains unclear.

Objective   To estimate the cost-effectiveness of implementing a pharmacist-prescribing intervention to improve BP control in the US.

Design, Setting, and Participants   This economic evaluation included a 5-state Markov model based on the pharmacist-prescribing intervention used in The Alberta Clinical Trial in Optimizing Hypertension (or RxACTION) (2009 to 2013). In the trial, control group patients received an active intervention, including a BP wallet card, education, and usual care. Data were analyzed from January to June 2023.

Main Outcomes and Measures   Cardiovascular (CV) events, end-stage kidney disease events, life years, quality-adjusted life years (QALYs), lifetime costs, and lifetime incremental cost-effectiveness ratio (ICER). CV risk was calculated using Framingham risk equations. Costs were based on the reimbursement rate for level 1 encounters, medication costs from published literature, and event costs from national surveys and pricing data sets. Quality of life was determined using a published catalog of EQ-5D utility values. One-way sensitivity analyses were used to assess alternative reimbursement values, a reduced time horizon of 5 years, alternative assumptions for BP reduction, and the assumption of no benefit to the intervention after 10 years. The model was expanded to the US population to estimate population-level cost and health impacts.

Results   Assumed demographics were mean (SD) age, 64 (12.5) years, 121 (49%) male, and a mean (SD) baseline BP of 150/84 (13.9/11.5) mm Hg. Over a 30-year time horizon, the pharmacist-prescribing intervention yielded 2100 fewer cases of CV disease and 8 fewer cases of kidney disease per 10 000 patients. The intervention was also associated with 0.34 (2.5th-97.5th percentiles, 0.23-0.45) additional life years and 0.62 (2.5th-97.5th percentiles, 0.53-0.73) additional QALYs. The cost savings were $10 162 (2.5th-97.5th percentiles, $6636-$13 581) per person due to fewer CV events with the pharmacist-prescribing intervention, even after the cost of the visits and medication adjustments. The intervention continued to produce benefits in more conservative analyses despite increased costs as the ICER ranged from $2093 to $24 076. At the population level, a 50% intervention uptake was associated with a $1.137 trillion in cost savings and would save an estimated 30.2 million life years over 30 years.

Conclusion and Relevance   These findings suggest that a pharmacist-prescribing intervention to improve BP control may provide high economic value. The necessary tools and resources are readily available to implement pharmacist-prescribing interventions across the US; however, reimbursement limitations remain a barrier.

Hypertension (HTN) is the leading preventable cause of death and disability throughout the world. 1 More than 100 million people in the US have HTN, a significant risk factor for the development of cardiovascular disease (CVD) and kidney disease. 2 Health care costs associated with HTN in the US alone exceeded $130 billion between 2003 and 2014. 3 Despite affordable medications and lifestyle interventions proven to reduce blood pressure (BP), BP control rates in the US are declining. 4 Currently, only 1 in 4 adults with HTN has their BP under control (ie, less than 130/80 mm Hg). 2

In 2020, the US Surgeon General issued a Call to Action to Control Hypertension, 5 which “seeks to avert the negative health effects of HTN across the US by identifying interventions that can be implemented, adapted, and expanded across diverse settings.” The goals include making HTN a national priority; ensuring the places where people live, learn, work, and play support HTN control; and optimizing patient care for HTN. One of the primary strategies promotes standardized treatment approaches and guideline-recommended care with an emphasis on team-based care. 5

Pharmacists are well placed in the community to screen and manage HTN because they see patients up to 10 times more frequently than physicians. 6 Numerous randomized clinical trials 7 - 10 of pharmacist-led case-finding and prescribing interventions have improved HTN outcomes. Given this evidence and the compelling need for new solutions to reduce the clinical and economic burden of uncontrolled HTN, we conducted a cost-effectiveness analysis of implementing pharmacist prescribing for HTN management in the US.

This economic evaluation followed the Consolidated Health Economic Evaluation Reporting Standards ( CHEERS ) reporting guideline. Per the Common Rule, institutional review and informed consent were not required because this research did not involve human participants.

A pharmacoeconomic model was developed in Microsoft Excel to assess the potential impact of pharmacist prescribing for HTN compared with usual care (status quo) on long-term costs and health outcomes in the US. The implementation of the model for a Canadian population has been previously described in greater detail 11 ; this structure was used and updated to reflect the US population and health care system. Briefly, the model was structured as a 5-state Markov model, with patients entering the model with uncontrolled HTN and no additional history of cardiovascular (CV) or kidney disease. Over time, patients were at risk of developing CV and/or kidney disease and subsequent death ( Figure 1 ). All patients were at risk for all-cause mortality based on general population life tables, with an increased risk of mortality in individuals following a CV event. The conceptual model assumed that the pharmacist-prescribing intervention would reduce BP, with a resultant decreased risk of CV and kidney disease; the costs of implementing pharmacist-prescribing HTN management were thus compared with long-term cost offsets as well as health and mortality benefits resulting from this BP reduction.

The base case scenario was a third-party payer perspective, with a 30-year time horizon, 1-year model cycles, and costs and quality-adjusted life years (QALYs) discounted at 3% per annum. 12 Results are reported at both the individual level and scaled up to the US population based on the number of individuals with uncontrolled HTN.

The Alberta Clinical Trial in Optimizing Hypertension (R x ACTION) was conducted in Alberta, Canada from 2009 to 2013. 10 This analysis was conducted in 2023 and used a model base case based on the mean 6-month reduction in systolic BP (SBP) (−18.3 mm Hg) observed with the pharmacist intervention in the R x ACTION study, which involved pharmacist assessment and counseling of BP, antihypertensive medication review, and prescribing antihypertensives in a face-to-face encounter. Pharmacist follow-up occurred every 4 weeks until BP was at goal for 2 consecutive visits followed by 12-week intervals for the remainder of the 24-week study duration. In the model, it was assumed that this would correspond to 6 visits in the first year and quarterly visits thereafter. For the comparator group, we assumed that BP would remain at baseline levels. We did not use the control group from the R x ACTION trial because it was an active intervention. Baseline clinical and demographic characteristics were based on the trial population (eTable 1 in Supplement 1 ).

The risk of CVD over time for the control arm was calculated based on Framingham risk equations for myocardial infarction (MI), stroke, heart failure (HF), and angina given baseline BP levels. 13 - 15 The association between SBP reduction in the intervention group and reduced risk of CVD was estimated using results from the Blood Pressure Lowering Treatment Trialists’ Collaboration. 16 A regression analysis was conducted based on the reported values for SBP and risk reduction of major CV events, and the resulting slope was used to estimate the impact of a 1-unit reduction on the relative risk. The resulting estimated association was a 0.026 (SE, 0.004) decrease in relative risk of CVD per each mm Hg decrease in SBP.

The impact of BP on kidney disease was characterized by the risk of end-stage kidney disease (ESKD), which was based on a reported association between BP categories and ESKD incidence observed in a US historical cohort study and a 25-year follow-up study. 17 , 18 Rates per 100 000 person-years were reported by category (normal, pre-HTN, stage 1 HTN, and stage 2 HTN), and converted to annual probabilities. For the modeled population at baseline, the mean BP corresponded to stage 1 HTN, which corresponded to an ESKD rate of 19.5 per 100 000 person-years, or an annual risk of 0.000194 per person. This annual risk was retained for the control arm. For the treatment arm, regression analysis of risk by BP category was conducted to estimate a risk reduction of 0.77 associated with observed BP reduction, which was applied to result in an annual ESKD probability of 0.000150 for the pharmacist-prescribing intervention group. Mortality was based on US life tables, with a hazard ratio of 1.71 applied to account for the increased risk of mortality in a population with CVD. 19

In the base case of the model, all pharmacist assessments were assumed to incur a cost of $23.10, reflecting the 2019 reimbursement rate for Current Procedural Terminology (CPT) 99211 (level 1 patient encounters). 20 Visits were assumed to be monthly for the first 3 months (assumed time until HTN became controlled), followed by quarterly, with 6 pharmacist visits in the first year and 4 annually after that. Given that the clinical model included pharmacist prescribing of medications, we assumed that patients receiving the intervention would incur an incremental medication cost of $32.78/mo, based on the mean monthly medication cost for individuals with HTN in the US. This was chosen conservatively to maximize the cost of the pharmacist intervention; the true incremental medication cost is likely lower given that some usual care patients receive physician-prescribed HTN medications, and pharmacist-prescribing interventions often result in discontinuation of less appropriate or effective medications. 10 , 21 Annual background all-cause health care costs for all individuals were based on age-specific values reported by the Agency for Healthcare Research and Quality. 22

For individuals experiencing health events, the cost of the event was stratified into the first-year postevent and subsequent years. Costs for CV events (ie, stroke, heart failure, angina, and MI) were based on reported values from a US microsimulation model of HTN screening strategies, which used Medical Expenditure Panel Survey data. The cost for ESKD was based on US Renal Data System data (eTable 2 in Supplement 1 ). 23 All costs were inflated to 2021 US dollar based on the US Consumer Price Index-Medical Care. 24

Health state utilities were taken from a published catalog of EQ-5D utility values in the US. Baseline utilities were 0.867 for patients without ESKD or CVD and age-adjusted using a utility decrement of 0.00029 per year after age 70 years. 25 The utility values included in the model were 0.694 for stroke, 0.725 for MI, 0.636 for HF, 0.709 for angina, and 0.708 for ESKD. Disease-specific utilities were assumed to be chronic and continued to apply years after the event.

One-way sensitivity analyses were used to examine the impact of variation in key inputs, including (1) increased costs per pharmacist visit, reflecting reimbursement values aligned with a greater likelihood of dissemination and sustainability—$100 for an initial visit and $50 per follow-up; (2) reduced time horizon to 5 years; (3) alternative assumptions regarding SBP decrease, ranging from −5 to −27 mm Hg; (4) examining each type of health benefit (ie, reductions in stroke, MI, angina, HF, and ESKD) in isolation; (5) assuming that the HTN benefit is only sustained for 10 years, after which point there is no benefit to the intervention; and (6) a conservative scenario in which the BP decrease is assumed to be −10 mm Hg, losing 50% of benefit at 5 years, and 100% of benefit at 10 years. The range of BP values explored in sensitivity analysis reflects existing literature on the effect of pharmacist interventions on BP. A meta-analysis 7 reported that pharmacist interventions decreased mean SBP by an additional −7.6 mm Hg compared with usual care, but the types of pharmacist interventions in the included studies were heterogeneous and did not include prescriptive authority. Alternatively, the cluster-randomized trial of a pharmacist-prescribing intervention in black barbershops reported a mean reduction in SBP of −27 mm Hg in the intervention group; thus our use of −18.3 mm Hg from the R x ACTION is reasonable.

In addition to the 1-way sensitivity analyses, a 1000-iteration probabilistic sensitivity analysis was conducted to reflect the impact of stochastic parameter uncertainty on results. This included probabilistic variability of cost, clinical, and health-related quality of life parameters, including the SBP reduction and the relationship between SBP and clinical event risk.

Base case cost-effectiveness results were expanded to the US population to estimate cumulative cost and health impacts over 30 years. Individual-level results output by the model were multiplied year-over-year by the estimated number of incidents and prevalent patients with uncontrolled HTN assumed to be accessing the intervention. This time horizon was chosen to capture the lifetime of the model cohort. The prevalence of uncontrolled HTN was estimated to be 92.1 million 26 ; it was assumed that 50% of eligible individuals would access the intervention. Over a 30-year time horizon, incident cases of HTN were added each year based on a US cohort study. 27 It was assumed that the 50% rate of intervention use would persist among incident cases. Clinical and cost outcomes were assessed over the time horizon.

Briefly, the R x ACTION trial enrolled 248 participants (mean [SD] age, 64 [12.5] years; 121 [49%] male; 41 [15%] currently smoked; and 109 [48%] had diabetes). The mean (SD) baseline BP was 150/84 (13.9/11.5) mm Hg with a mean (SD) of 1.7 (1.2) antihypertensives per participant. The pharmacist intervention achieved a significant reduction in SBP at 6 months compared with the active control group (−18.3 mm Hg vs −11.8 mm Hg, respectively; P  < .001).

In the base case analysis over a 30-year time horizon, the pharmacist intervention was associated with 2100 fewer cases of CVD and 8 fewer cases of kidney disease per 10 000 patients. Per patient, the intervention was associated with 0.34 additional life years (discounted) and 0.62 additional QALYs (discounted) ( Table 1 ). The intervention also resulted in overall cost savings of $10 162 per person, as the cost reduction associated with fewer CV events more than offset the cost of pharmacist visits and medication adjustments ( Table 1 ). When comparing health care costs only (ie, excluding the costs of the intervention itself) mean costs were $189 648 in the control group and $172 167 in the intervention group, for a savings of $17 481. As the pharmacist-prescribing intervention was associated with both better health outcomes and lower costs, it was found to be dominant (discounted and undiscounted). Results were robust in the probabilistic sensitivity analysis, because 100% of probabilistic iterations were in the economically dominant quadrant of the cost-utility plane ( Figure 2 ).

In 1-way sensitivity analyses, results remained dominant when pharmacist costs were increased from the CPT level 1 reimbursement rate of $23.10 to $100 for an initial visit and $50 per follow-up visit, indicating that further incentivizing the pharmacist intervention would not jeopardize the resulting value of the service and would offset the pharmacist labor costs ( Table 2 ). The intervention also continued to dominate usual care when benefits were only accrued for 10 years, at which point the intervention was assumed to be equivalent to usual care. Although in this scenario, cost savings were reduced to $5744 and QALY benefits were reduced to 0.08 per patient. This was further reduced to cost savings of $521 in a scenario where the SBP reduction was reduced to −10 mm Hg, with 50% efficacy loss at 5 years and 100% efficacy at 10 years. However, economic dominance was still retained. In a series of more conservative analyses (ie, reduced effectiveness of a less-intensive intervention, considering each respective health outcome in isolation), the intervention continued to result in health benefits, but with an increase in costs; incremental cost-effectiveness ratios ranged from $2093 to $24 076, well within standard thresholds for cost-effectiveness ( Table 2 ). Reducing the time horizon to 5 years yielded an incremental cost-effectiveness ratio of $16 987.

In a more comprehensive 1-way assessment of the association between incremental costs and QALYs across a range of SBP values, the pharmacist intervention was associated with increased QALYs and was associated with reduced costs for SBP reduction of −9 mm Hg or greater (eFigure 1 in Supplement 1 ). For a hypothetical SBP reduction between −5 and −9 mm Hg, although costs were greater for the pharmacist intervention, incremental cost-effectiveness ratios remained at cost-effective levels, ranging from $500 to $16 000. When the model with base case settings was expanded to the population level, it was estimated that with a 50% access rate, the pharmacist intervention would lead to $1.137 trillion in cost savings and save 30.2 million life years over 30 years ( Figure 3 ).

Pharmacist interventions significantly improve BP control, 7 but the economic impact of widespread adoption of such interventions has been unclear. Our study demonstrates that a pharmacist prescribing intervention would save $10 162 per person over a 30-year time horizon with and at the population level, a cumulative savings of $1.13 trillion dollars. These savings were largely attributable to a reduction in CV events due to improved BP control with the intervention. These findings mirror those from a similar analysis evaluating the implementation of this model in Canada. 11 The cost savings in that study were less at $6364 per person, translating to a population benefit of 15.7 billion over 30 years, likely due to the lower overall health care costs in Canada compared with the US.

There is a critical need for innovative approaches, such as pharmacist-led interventions, to improve BP control. Between 2010 and 2019, there was a 23.1% increase in HTN-related mortality in the US. 28 In 2019, the rate of HTN-related death among Black individuals aged 35 to 64 years was 96.3 events per 100 000—the highest of any race or ethnicity. Importantly, pharmacist-led interventions have been shown to significantly improve BP control among Black individuals and individuals of racial and ethnic minoritized groups. 8 , 29 - 31 There is also a sense of urgency for broader implementation of pharmacist interventions to improve BP control given the worsening shortage of primary care clinicians, which could reach between 17 800 and 48 000 by the year 2034. 32 Given that 95% of individuals in the US live within 5 miles of a pharmacy, pharmacists are a possible solution to improve care access. 33

Widespread implementation of pharmacist-prescribing interventions targeting uncontrolled HTN is feasible but will require continued advancement in pharmacist scope of practice legislation and eligibility for reimbursement through the Centers for Medicare & Medicaid Services. Today, 49 states and the District of Columbia have legislative provisions allowing pharmacist prescriptive authority through collaborative practice agreements, standing orders, or statewide protocols. 34 Such collaborative models often occur between pharmacists and physicians and permit prescriptive authority to pharmacists to initiate, adjust, or discontinue medications for specific medical conditions per an agreed-upon protocol or current clinical practice guidelines. 35 This approach is also evidence-based as it has been used in randomized trials demonstrating the effectiveness of physician-pharmacist collaborative models for HTN. 8 , 30 Expansion of prescriptive authority for pharmacists could increase access for those with limited or no source of primary care, which disproportionately affects males, underrepresented minorities, the uninsured, and those living in the southern US. 36

While pharmacists may participate in collaborative models, pharmacists are infrequently recognized by payers because they are not recognized clinicians under the Social Security Act. Pharmacists can bill for services incident to those provided by a physician or advanced practice clinician; however, this is limited to Level 1, which is only $23.10 for 5 minutes of clinical services and insufficient for the level of service provided. 37 Our analysis showed that a pharmacist-prescribing intervention would remain cost-effective if pharmacists received a hypothetical reimbursement of $100 for the initial visit and $50 for each follow-up. While some states have recently passed clinician status legislation, much work remains to ensure pharmacists are adequately compensated for the clinical services they provide.

This study had limitations. The cost savings assume a 50% uptake of the intervention, and the savings magnitude depends on uptake. However, if pharmacists are appropriately incentivized through adequate reimbursement for providing the service, this level of uptake is likely an underestimate. Another assumption is that BP control did not change in the comparator group, and a proportion of patients in the comparator group may have improved BP control with usual care. Further, the proportion of patients with uncontrolled HTN continues to rise and has only worsened because of the COVID-19 pandemic. These findings cannot be generalized to other populations with HTN (eg, pregnancy), and we were unable to determine how alternative delivery methods (eg, telehealth) would impact the cost-effectiveness of this model.

This economic analysis suggests that pharmacist-prescribing interventions are cost-effective, result in significant estimated savings for the health care system, and are economically dominant. Assuming a 50% adoption rate, pharmacist-prescribing interventions would save an estimated $10 162 per person over a 30-year time horizon with cumulative population-level savings of more than a trillion dollars. The necessary tools (eg, collaborative practice, treatment algorithms) and resources (eg, patient access to community pharmacies) are readily available to implement pharmacist-prescribing interventions across the US; however, reimbursement limitations remain a barrier.

Accepted for Publication: September 24, 2023.

Published: November 3, 2023. doi:10.1001/jamanetworkopen.2023.41408

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Dixon DL et al. JAMA Network Open .

Corresponding Author: Dave L. Dixon, PharmD, Department of Pharmacotherapy and Outcomes Science, Center for Pharmacy Practice Innovation, Virginia Commonwealth University School of Pharmacy, 410 N 12th St, Box 980533, Richmond, VA 23298-0533 ( [email protected] ).

Author Contributions: Drs Dixon and Johnston had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Dixon, Johnston, Marra, Tsuyuki.

Acquisition, analysis, or interpretation of data: Dixon, Johnston, Patterson, Tsuyuki.

Drafting of the manuscript: Dixon, Johnston.

Critical review of the manuscript for important intellectual content: Dixon, Patterson, Marra, Tsuyuki.

Statistical analysis: Johnston.

Administrative, technical, or material support: Dixon, Marra.

Supervision: Dixon, Tsuyuki.

Conflict of Interest Disclosures: Dr Dixon reported receiving personal fees from Mercatus Center during the conduct of the study and receiving grants from Boehringer Ingelheim outside the submitted work. Dr Johnston reported receiving funding from the Canadian Pharmacists association outside the submitted work. Dr Patterson reported receiving honoraria from Mercatus Center during the conduct of the study and working at the National Pharmaceutical Council outside the submitted work. Dr Tsuyuki reported receiving grants from Merck, Sanofi, AstraZeneca, and Pfizer and being the President of Hypertension Canada and the editor-in-chief of the Canadian Pharmacists Journal outside the submitted work. No other disclosures were reported.

Funding/Support: The Mercatus Center at George Mason University commissioned this work with authors D.L.D. and J.P.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.173(4); 2000 Oct

Evidence-Based Case Review

Treating hypertension, rosemary morgan.

1 Department of Medicine for the Elderly Arrowe Park Hospital Upton Wirral L49 5PE, UK

CASE HISTORY

The patient, a 66-year-old retired bar owner, Mr C, was admitted to the hospital with a sudden onset of weakness affecting his right arm and right leg. His wife had been unable to get him out of bed earlier that morning. She had noted that his speech was slurred and initially had thought that he was very confused. The day before, he had knocked his head against a car door but had seemed all right at the time. He had no history of transient ischemic attacks. A diagnosis of essential hypertension had been made 4 years previously, and angina pectoris had been diagnosed 2 years previously. Although his general practitioner had prescribed antihypertensive treatment, Mr C did not like the side effects of the drug and stopped taking it 3½ years ago. His only other medication was sublingual glyceryl trinitrate (nitroglycerin) as required. He smoked 20 cigarettes a day, having started at age 20, and consumed 40 units of alcohol per week. Mr C's father had died of a myocardial infarction at age 69, and his mother had died of a stroke at age 70. He had no siblings.

Physical examination revealed his power to be reduced at 3/5 in his right arm and right leg, and he had an expressive dysphasia. Tone was increased on the right, with a right extensor plantar response, and he had hyperreflexia on the right compared with the left. He was continent and had fair sitting balance.

A 12-lead electrocardiogram confirmed that Mr C was in sinus rhythm with left ventricular hypertrophy and an old inferior myocardial infarction. His full blood cell count, erythrocyte sedimentation rate, random blood glucose concentration, and levels of troponin T, urea, creatinine, and electrolytes were all within the normal range. A fasting lipid profile revealed a cholesterol concentration of 7.2 mmol/L (278 mg/dL). A computed tomographic scan of the brain showed a cerebral infarct in the internal capsule. Doppler studies showed no significant stenosis of the carotid arteries. Echocardiography showed good left ventricular function with an ejection fraction of 59% and mild mitral regurgitation. After rehabilitation, Mr C was discharged home, independently mobile with a walker.

When the patient was seen in the outpatient clinic 8 weeks later, his primary care physician had sent a letter expressing concern at Mr C's continued raised blood pressure, which in the clinic was 182/102 mm Hg sitting. On further inquiry, the patient indicated that although he had been discharged home with the medications aspirin, pravastatin, and atenolol, he had taken only aspirin after discharge. He had not had any adverse effects from the drugs but was reluctant to take any medication and wanted to know exactly what evidence existed that he would benefit from taking regular antihypertensive medication, especially because he was totally free of symptoms.

WHAT IS THE EVIDENCE FOR TREATING ONGOING HYPERTENSION IN PATIENTS WHO HAVE HAD A STROKE?

Searching for the evidence.

With increasing access to the Internet and articles on health in popular media, patients are becoming more knowledgeable about their illnesses, and some want to discuss with their physician the information they obtain from these sources. For physicians to keep abreast of every new development in every field of medicine is impossible, but it is important that they develop skills in seeking new information that they can assess and use to make informed decisions.

Mr C wants to know what evidence exists that would support his taking antihypertensive and lipid-lowering drugs. Although most of the standard medical textbooks clearly state that hypertension is a risk factor for stroke (see box) and should be treated, few quote the exact evidence on which this conclusion is based.

The ideal evidence to convince Mr C to take antihypertensive drugs would be large randomized controlled trials showing a substantial benefit in patients who received treatment. One of the easiest and most readily available sources to start with is MEDLINE. First, I need to decide which words to use in my search and how far back to extend the search. Although initially I was going to use “hypertension” and “stroke,” by consulting MEDLINE's thesaurus, I learn that “cerebrovascular disorders” is a better term to use than “stroke.” I decide to go back as far as 1990 for the search.

Appraising the evidence

When I use the terms “hypertension” and “cerebrovascular disorders,” MEDLINE provides 970 records, but when I limit the search to randomized controlled trials and only those in the English language, it gives 43 references. Although it might be possible to restrict the search further, I prefer to print out the references and look at the title of the study and the journal in which the study was published. By doing this, I was able to select 3 references that may answer Mr C's question. 1 , 2 , 3

Summarizing the evidence

Fortunately, someone has already done an overview of 14 randomized controlled trials of blood pressure, stroke, and coronary heart disease. 1 These trials involve a total of 37,000 people randomly allocated to antihypertensive treatment (mainly diuretics or β blockers), with a mean treatment duration of 5 years. For most of these trials, a cutoff blood pressure of 140/90 mm Hg was used to determine hypertension. The results indicate that a decrease in the diastolic blood pressure of 5 to 6 mm Hg reduces the risk of stroke by 42% and coronary heart disease by 14%. The Systolic Hypertension in the Elderly Program, 2 in which 4,736 people from 447,921 screened participants aged 60 years and older were randomly allocated to either active or placebo treatment, showed that the treatment of isolated systolic hypertension in elderly people decreases their risk of stroke by 36%.

In another study, 4,396 patients aged 65 to 74 years with mild to moderate hypertension were randomly assigned to receive diuretic, β blocker, or placebo. 3 Patients in the treatment group had a 25% reduction in stroke and a 19% reduction in coronary artery events. In this study, supported by others, 4 diuretics seem to be superior to β blockers in reducing the risk of stroke in older people with hypertension. None of the trials included very elderly patients, as a consequence of which the question of whether they will benefit is somewhat uncertain (a trial is under way to answer this). 5

Firm evidence exists that treating hypertension in persons at risk is beneficial and substantially reduces the risk of both stroke and, to a lesser extent, coronary heart disease. I relayed the information back to Mr C, who is now agreeable to taking his antihypertensive drugs. Given the findings on the electrocardiogram of an old myocardial infarction and his history of angina, I have decided to prescribe a β blocker. If these were absent, however, the available evidence would support the use of a thiazide diuretic as first-line treatment. If on subsequent review his blood pressure is not adequately controlled with a β blocker, I will add a thiazide diuretic.

Summary points

• Reduction of diastolic blood pressure by 5 to 6 mm Hg reduces the risk of stroke by 42% in hypertensive patients
• The same reduction in diastolic blood pressure reduces the risk of coronary heart disease by 14%
• Most of the randomized controlled trials have used either β blockers or diuretics as the antihypertensive agent
• Diuretics (thiazides) seem to be superior to β blockers in reducing the risk of stroke

This article was published in Student BMJ 2000;6:228-229

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android . Learn more here!

• Remote Access
• Save figures into PowerPoint
• Download tables as PDFs

Chapter 12. Hypertension

Michelle Z. Farland

• Download Chapter PDF

Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. Please consult the latest official manual style if you have any questions regarding the format accuracy.

Download citation file:

• Search Book

Jump to a Section

• Learning Objectives
• Background and Introduction
• Measuring Blood Pressure and Pulse
• Lifestyle Interventions for Hypertension
• Medication Management
• Service Development
• Hypertension: Patient Case
• Implementing Services for Hypertension in an Independent Community Pharmacy—An Interview
• Summary Points
• Bibliography
• Full Chapter
• Supplementary Content

After reading this chapter, the student pharmacist, community practice resident, or pharmacist should be able to:

Accurately measure blood pressure (BP).

Appropriately classify severity of hypertension (HTN) by using the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) staging classification.

Identify compelling indications to assist with selection of appropriate pharmacotherapeutic agents for treatment of HTN.

Educate patients of the impact of lifestyle changes on BP control.

Develop pharmacotherapy treatment plans for patients with HTN, including those with compelling indications, difficult to treat HTN, and special populations.

Identify potential barriers to implementing services for patients with HTN in a community pharmacy.

Design workflow in a community pharmacy to establish and maintain services for patients with HTN.

Epidemiology of Hypertension in the United States

The 2011 Update on Heart Disease and Stroke Statistics indicates that 29% of adults (≥18 years) in the United States have high BP. 1 According to the most recent National Health and Nutrition Examination Survey (NHANES), 30.4% (66.9 million) of US adults (≥18 years) have HTN, defined as average BP ≥140/90 mm Hg, or currently using blood pressure lowering medication. 2

HTN prevalence varies with age, sex, race, and ethnicity. 1 , 3 The prevalence of high BP is greater in men in the age group of 18–44 years. Women and men have equal prevalence from the age of 45–64 years. Women have a higher prevalence of high BP starting at age 65. Prevalence of HTN is greatest among black Americans. Black Americans have a higher average BP and develop HTN at an earlier age than white Americans. American Indians and Native Alaskans also have increased prevalence compared with white and Asian adults. Puerto Rican Americans have the highest rate of HTN-related deaths compared with other Hispanic populations. The rate of HTN-related mortality is similar between Hispanic and non-Hispanic whites. Being born outside the United States, speaking a non-English language at home, and fewer years of living in the United States are associated with decreased prevalence of HTN.

Sign in or create a free Access profile below to access even more exclusive content.

With an Access profile, you can save and manage favorites from your personal dashboard, complete case quizzes, review Q&A, and take these feature on the go with our Access app.

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Please Wait

Medical Pharmacology

At a glance, michael j. neal.

• Commonly used Drugs
• Your Feedback
• Become a reviewer
• More student books
• Student Apps
• Join an e-mail list

Buy/find out more

Case Studies

Case 4: hypertension.

A routine blood pressure measurement at a GP surgery revealed that the patient, a 50–year–old man, had a blood pressure of 180/110. Several repeated visits confirmed these pressures. No cause was found for the hypertension although the patient smoked 20 cigarettes a day and was slightly obese.

(a) At this time, the patient felt perfectly well and asked why he should be worried about his blood pressure. What will you tell him?

Show Answer

That his high blood pressure increases his risk of coronary artery disease, heart failure, renal failure, and stroke.

(b) What general advice will you give?

Stress the importance of giving up smoking. Suggest that he loses weight by eating less and taking more exercise. Also suggest a reduction in alcohol consumption and avoidance of added salt as both of these may be contributory factors involved in his hypertension.

(c) What antihypertensive drug might you consider for initial therapy?

The main drugs used to treat hypertension are the thiazides, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin-II receptor antagonists (ARAs) and calcium channel blockers (CCBs). The response to ACEIs and ARAs is often reduced in patients over the age of 55 years probably because they have lower renin levels than younger patients. Therefore, a thiazide (e.g. bendroflumethiazide) or CCB (e.g. amlodipine) would be a reasonable choice.

(d) After 3 months his blood pressure is still not controlled. What factors might be contributing to this failure of treatment and what should you do next?

The most likely explanation for the failure to control the patient’s blood pressure is lack of compliance. Tactful questions may reveal that the drug selected for initial therapy has unwanted effects that the patient finds unacceptable.

If you are convinced the patient is taking his medicine as directed, then a second drug should be added. For patients taking a thiazide or CCB, the addition of an ACEI (e.g. captopril) or ARA (losartan) is appropriate because both diuresis and vasodilatation stimulate the renin-angiotensin system and turn non–renin–dependent hypertension into renin–dependent hypertension. Some patients may require three or even four drugs to control their hypertension.

Multidrug therapy is likely to reduce compliance but this can be improved by the use of sustained–release formulations and fixed–dose combinations (e.g. Co–zidocapt, which is captopril in combination with hydrochlorothiazide).

Please see Chapters 19 and 25.

Print Case | « Previous Case | Next Case »

College of Pharmacy

Kennelty, Casteel Study on Team-Based Hypertension Earns $17.9M

Two University of Iowa researchers have been approved for nearly $18 million to help older adults with multiple chronic medical conditions better manage their hypertension.  

Korey Kennelty , the Patrick E. Keefe Professor in Pharmacy in the  College of Pharmacy  and the vice chair for research and implementation science in the Department of Family Medicine , and  Carri Casteel , professor in the Department of Occupational and Environmental Health and director of the Injury Prevention Research Center in the  College of Public Health , will test two team-based care approaches to manage high blood pressure in older adults. 

In the first approach, the patient will work with a health care team that includes nurses and primary care providers. In the second approach, pharmacists also will be part of the health care team.

See full story in Iowa Now .

Ohio State nav bar

The Ohio State University

• BuckeyeLink
• Find People
• Search Ohio State

Patient Case Presentation

Mr. E.A. is a 40-year-old black male who presented to his Primary Care Provider for a diabetes follow up on October 14th, 2019. The patient complains of a general constant headache that has lasted the past week, with no relieving factors. He also reports an unusual increase in fatigue and general muscle ache without any change in his daily routine. Patient also reports occasional numbness and tingling of face and arms. He is concerned that these symptoms could potentially be a result of his new diabetes medication that he began roughly a week ago. Patient states that he has not had any caffeine or smoked tobacco in the last thirty minutes. During assessment vital signs read BP 165/87, Temp 97.5 , RR 16, O 98%, and HR 86. E.A states he has not lost or gained any weight. After 10 mins, the vital signs were retaken BP 170/90, Temp 97.8, RR 15, O 99% and HR 82. Hg A1c 7.8%, three months prior Hg A1c was 8.0%.  Glucose  180 mg/dL (fasting).  FAST test done; negative for stroke. CT test, Chem 7 and CBC have been ordered.

Past medical history

Diagnosed with diabetes (type 2) at 32 years old

Overweight, BMI of 31

Had a cholecystomy at 38 years old

Diagnosed with dyslipidemia at 32 years old

Past family history

Mother alive, diagnosed diabetic at 42 years old 

Father alive with Hypertension diagnosed at 55 years old

Brother alive and well at 45 years old

Sister alive and obese at 34 years old 

Pertinent social history

Social drinker on occasion

Smokes a pack of cigarettes per day

Works full time as an IT technician and is in graduate school

Pharmacy Case Studies for Pharmacists & Medical Sciences Students

Pharmacists and healthcare practitioners are required to demonstrate knowledge and understanding of the application of therapeutics in clinical practice. Pharmacists must ensure patient safety and achieve desired health outcomes through effective decision-making. The idea of designing these case studies is to meet the needs and challenges of a modern pharmacy undergraduate curriculum. Case studies are increasingly used in pharmacy undergraduate as well as postgraduate education.

Each chapter contains five case studies, increasing in complexity from those we would expect first-year students to complete (Level 1) through to cases designed for fourth-year/pre-registration students (Level M). The chapters have been designed to follow approximately the British National Formulary chapters for ease of use. Case study scenarios include both community and hospital pharmacy situations as suited to the disease and pharmaceutical care provision.

This section is only for Bangladeshi Pharmacy/Medical Students & Professionals !

Cardiovascular case studies by Narinder Bhalla

Case study level 1 – Angina Case study level 2 – Hypertension Case study level 3 – Atrial fibrillation Case study level Ma – Heart failure Case study level Mb – Myocardial infarction

Respiratory system case studies by Soraya Dhillon and Andrzej Kostrzewski

Case study level 1 – Asthma – community Case study level 2 – Asthma – acute on chronic Case study level 3 – Chronic obstructive pulmonary disease (COPD) with co-morbidity Case study level Ma – COPD Case study level Mb – Brittle asthma

Obstetrics, gynaecology and UTI case studies by Alka Mistry

Case study level 1 – Primary dysmenorrhoea Case study level 2 – Urinary tract infections in pregnancy Case study level 3 – Pelvic inflammatory disease Case study level Ma – Endometriosis management in secondary care Case study level Mb – Management of severe pre-eclampsia/ eclampsia

Liver disease case studies by Caron Weeks and Mark Tomlin

Case study level 1 – Alcoholic cirrhosis; alcohol withdrawal Case study level 2 – Alcoholic cirrhosis; management of bleeding risk and treatment for the maintenance of alcohol abstinence Case study level 3 – Hepatic encephalopathy and ascites Case study level Ma – Pulmonary tuberculosis Case study level Mb – Liver failure  

• Case study for pharmacist
• Pharmacy case study

You might be interested in

Liver disease case studies: Case study level 1 – Alcoholic cirrhosis; alcohol withdrawal

Cardiovascular case studies: case study level mb – myocardial infarction, cardiovascular case studies : case study level 3 – atrial fibrillation.

Nice sources

How to read all case studies?

Leave a Reply Cancel reply

Your email address will not be published.

{{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More {{/message}}

{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More {{/message}}

Submitting…

This site uses Akismet to reduce spam. Learn how your comment data is processed .

Press Release: 4 Symposiums at BioPharma Asia Convention 2013, Singapore

Notes on Bioinformatics Basic

Case Study: Treating Chronic Hypertension in Pregnancy

Public Health Matters: Seacrest Studios’ Impact on Children’s Hospitals and Healing Through Broadcasting

Recombinant Zoster Vaccine Demonstrates High Protection Against Shingles in Adult Patients

Pharmacy Focus: Limited Series - Celebrity Endorsements in Public Health

CDC Confirms Case of H5N1 Bird Flu in the United States, Noting Risk to Public Health Remains Low

Study: Frexalimab Shows Sustained Reduction of Disease Activity for Multiple Sclerosis

2 Commerce Drive Cranbury, NJ 08512

609-716-7777

• Open access
• Published: 22 April 2024

Artificial intelligence and medical education: application in classroom instruction and student assessment using a pharmacology & therapeutics case study

• Kannan Sridharan 1 &
• Reginald P. Sequeira 1  

BMC Medical Education volume  24 , Article number:  431 ( 2024 ) Cite this article

85 Accesses

2 Altmetric

Metrics details

Artificial intelligence (AI) tools are designed to create or generate content from their trained parameters using an online conversational interface. AI has opened new avenues in redefining the role boundaries of teachers and learners and has the potential to impact the teaching-learning process.

In this descriptive proof-of- concept cross-sectional study we have explored the application of three generative AI tools on drug treatment of hypertension theme to generate: (1) specific learning outcomes (SLOs); (2) test items (MCQs- A type and case cluster; SAQs; OSPE); (3) test standard-setting parameters for medical students.

Analysis of AI-generated output showed profound homology but divergence in quality and responsiveness to refining search queries. The SLOs identified key domains of antihypertensive pharmacology and therapeutics relevant to stages of the medical program, stated with appropriate action verbs as per Bloom’s taxonomy. Test items often had clinical vignettes aligned with the key domain stated in search queries. Some test items related to A-type MCQs had construction defects, multiple correct answers, and dubious appropriateness to the learner’s stage. ChatGPT generated explanations for test items, this enhancing usefulness to support self-study by learners. Integrated case-cluster items had focused clinical case description vignettes, integration across disciplines, and targeted higher levels of competencies. The response of AI tools on standard-setting varied. Individual questions for each SAQ clinical scenario were mostly open-ended. The AI-generated OSPE test items were appropriate for the learner’s stage and identified relevant pharmacotherapeutic issues. The model answers supplied for both SAQs and OSPEs can aid course instructors in planning classroom lessons, identifying suitable instructional methods, establishing rubrics for grading, and for learners as a study guide. Key lessons learnt for improving AI-generated test item quality are outlined.

Conclusions

AI tools are useful adjuncts to plan instructional methods, identify themes for test blueprinting, generate test items, and guide test standard-setting appropriate to learners’ stage in the medical program. However, experts need to review the content validity of AI-generated output. We expect AIs to influence the medical education landscape to empower learners, and to align competencies with curriculum implementation. AI literacy is an essential competency for health professionals.

Peer Review reports

Artificial intelligence (AI) has great potential to revolutionize the field of medical education from curricular conception to assessment [ 1 ]. AIs used in medical education are mostly generative AI large language models that were developed and validated based on billions to trillions of parameters [ 2 ]. AIs hold promise in the incorporation of history-taking, assessment, diagnosis, and management of various disorders [ 3 ]. While applications of AIs in undergraduate medical training are being explored, huge ethical challenges remain in terms of data collection, maintaining anonymity, consent, and ownership of the provided data [ 4 ]. AIs hold a promising role amongst learners because they can deliver a personalized learning experience by tracking their progress and providing real-time feedback, thereby enhancing their understanding in the areas they are finding difficult [ 5 ]. Consequently, a recent survey has shown that medical students have expressed their interest in acquiring competencies related to the use of AIs in healthcare during their undergraduate medical training [ 6 ].

Pharmacology and Therapeutics (P & T) is a core discipline embedded in the undergraduate medical curriculum, mostly in the pre-clerkship phase. However, the application of therapeutic principles forms one of the key learning objectives during the clerkship phase of the undergraduate medical career. Student assessment in pharmacology & therapeutics (P&T) is with test items such as multiple-choice questions (MCQs), integrated case cluster questions, short answer questions (SAQs), and objective structured practical examination (OSPE) in the undergraduate medical curriculum. It has been argued that AIs possess the ability to communicate an idea more creatively than humans [ 7 ]. It is imperative that with access to billions of trillions of datasets the AI platforms hold promise in playing a crucial role in the conception of various test items related to any of the disciplines in the undergraduate medical curriculum. Additionally, AIs provide an optimized curriculum for a program/course/topic addressing multidimensional problems [ 8 ], although robust evidence for this claim is lacking.

The existing literature has evaluated the knowledge, attitude, and perceptions of adopting AI in medical education. Integration of AIs in medical education is the need of the hour in all health professional education. However, the academic medical fraternity facing challenges in the incorporation of AIs in the medical curriculum due to factors such as inadequate grounding in data analytics, lack of high-quality firm evidence favoring the utility of AIs in medical education, and lack of funding [ 9 ]. Open-access AI platforms are available free to users without any restrictions. Hence, as a proof-of-concept, we chose to explore the utility of three AI platforms to identify specific learning objectives (SLOs) related to pharmacology discipline in the management of hypertension for medical students at different stages of their medical training.

Study design and ethics

The present study is observational, cross-sectional in design, conducted in the Department of Pharmacology & Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Kingdom of Bahrain, between April and August 2023. Ethical Committee approval was not sought given the nature of this study that neither had any interaction with humans, nor collection of any personal data was involved.

Study procedure

We conducted the present study in May-June 2023 with the Poe© chatbot interface created by Quora© that provides access to the following three AI platforms:

Sage Poe [ 10 ]: A generative AI search engine developed by Anthropic © that conceives a response based on the written input provided. Quora has renamed Sage Poe as Assistant © from July 2023 onwards.

Claude-Instant [ 11 ]: A retrieval-based AI search engine developed by Anthropic © that collates a response based on pre-written responses amongst the existing databases.

ChatGPT version 3.5 [ 12 ]: A generative architecture-based AI search engine developed by OpenAI © trained on large and diverse datasets.

We queried the chatbots to generate SLOs, A-type MCQs, integrated case cluster MCQs, integrated SAQs, and OSPE test items in the domain of systemic hypertension related to the P&T discipline. Separate prompts were used to generate outputs for pre-clerkship (preclinical) phase students, and at the time of graduation (before starting residency programs). Additionally, we have also evaluated the ability of these AI platforms to estimate the proportion of students correctly answering these test items. We used the following queries for each of these objectives:

Specific learning objectives

Can you generate specific learning objectives in the pharmacology discipline relevant to undergraduate medical students during their pre-clerkship phase related to anti-hypertensive drugs?

Can you generate specific learning objectives in the pharmacology discipline relevant to undergraduate medical students at the time of graduation related to anti-hypertensive drugs?

A-type MCQs

In the initial query used for A-type of item, we specified the domains (such as the mechanism of action, pharmacokinetics, adverse reactions, and indications) so that a sample of test items generated without any theme-related clutter, shown below:

Write 20 single best answer MCQs with 5 choices related to anti-hypertensive drugs for undergraduate medical students during the pre-clerkship phase of which 5 MCQs should be related to mechanism of action, 5 MCQs related to pharmacokinetics, 5 MCQs related to adverse reactions, and 5 MCQs should be related to indications.

The MCQs generated with the above search query were not based on clinical vignettes. We queried again to generate MCQs using clinical vignettes specifically because most medical schools have adopted problem-based learning (PBL) in their medical curriculum.

Write 20 single best answer MCQs with 5 choices related to anti-hypertensive drugs for undergraduate medical students during the pre-clerkship phase using a clinical vignette for each MCQ of which 5 MCQs should be related to the mechanism of action, 5 MCQs related to pharmacokinetics, 5 MCQs related to adverse reactions, and 5 MCQs should be related to indications.

We attempted to explore whether AI platforms can provide useful guidance on standard-setting. Hence, we used the following search query.

Can you do a simulation with 100 undergraduate medical students to take the above questions and let me know what percentage of students got each MCQ correct?

Integrated case cluster MCQs

Write 20 integrated case cluster MCQs with 2 questions in each cluster with 5 choices for undergraduate medical students during the pre-clerkship phase integrating pharmacology and physiology related to systemic hypertension with a case vignette.

Write 20 integrated case cluster MCQs with 2 questions in each cluster with 5 choices for undergraduate medical students during the pre-clerkship phase integrating pharmacology and physiology related to systemic hypertension with a case vignette. Please do not include ‘none of the above’ as the choice. (This modified search query was used because test items with ‘None of the above’ option were generated with the previous search query).

Write 20 integrated case cluster MCQs with 2 questions in each cluster with 5 choices for undergraduate medical students at the time of graduation integrating pharmacology and physiology related to systemic hypertension with a case vignette.

Integrated short answer questions

Write a short answer question scenario with difficult questions based on the theme of a newly diagnosed hypertensive patient for undergraduate medical students with the main objectives related to the physiology of blood pressure regulation, risk factors for systemic hypertension, pathophysiology of systemic hypertension, pathological changes in the systemic blood vessels in hypertension, pharmacological management, and non-pharmacological treatment of systemic hypertension.

Write a short answer question scenario with moderately difficult questions based on the theme of a newly diagnosed hypertensive patient for undergraduate medical students with the main objectives related to the physiology of blood pressure regulation, risk factors for systemic hypertension, pathophysiology of systemic hypertension, pathological changes in the systemic blood vessels in hypertension, pharmacological management, and non-pharmacological treatment of systemic hypertension.

Write a short answer question scenario with questions based on the theme of a newly diagnosed hypertensive patient for undergraduate medical students at the time of graduation with the main objectives related to the physiology of blood pressure regulation, risk factors for systemic hypertension, pathophysiology of systemic hypertension, pathological changes in the systemic blood vessels in hypertension, pharmacological management, and non-pharmacological treatment of systemic hypertension.

Can you generate 5 OSPE pharmacology and therapeutics prescription writing exercises for the assessment of undergraduate medical students at the time of graduation related to anti-hypertensive drugs?

Can you generate 5 OSPE pharmacology and therapeutics prescription writing exercises containing appropriate instructions for the patients for the assessment of undergraduate medical students during their pre-clerkship phase related to anti-hypertensive drugs?

Can you generate 5 OSPE pharmacology and therapeutics prescription writing exercises containing appropriate instructions for the patients for the assessment of undergraduate medical students at the time of graduation related to anti-hypertensive drugs?

Both authors independently evaluated the AI-generated outputs, and a consensus was reached. We cross-checked the veracity of answers suggested by AIs as per the Joint National Commission Guidelines (JNC-8) and Goodman and Gilman’s The Pharmacological Basis of Therapeutics (2023), a reference textbook [ 13 , 14 ]. Errors in the A-type MCQs were categorized as item construction defects, multiple correct answers, and uncertain appropriateness to the learner’s level. Test items in the integrated case cluster MCQs, SAQs and OSPEs were evaluated with the Preliminary Conceptual Framework for Establishing Content Validity of AI-Generated Test Items based on the following domains: technical accuracy, comprehensiveness, education level, and lack of construction defects (Table  1 ). The responses were categorized as complete and deficient for each domain.

The pre-clerkship phase SLOs identified by Sage Poe, Claude-Instant, and ChatGPT are listed in the electronic supplementary materials 1 – 3 , respectively. In general, a broad homology in SLOs generated by the three AI platforms was observed. All AI platforms identified appropriate action verbs as per Bloom’s taxonomy to state the SLO; action verbs such as describe, explain, recognize, discuss, identify, recommend, and interpret are used to state the learning outcome. The specific, measurable, achievable, relevant, time-bound (SMART) SLOs generated by each AI platform slightly varied. All key domains of antihypertensive pharmacology to be achieved during the pre-clerkship (pre-clinical) years were relevant for graduating doctors. The SLOs addressed current JNC Treatment Guidelines recommended classes of antihypertensive drugs, the mechanism of action, pharmacokinetics, adverse effects, indications/contraindications, dosage adjustments, monitoring therapy, and principles of monotherapy and combination therapy.

The SLOs to be achieved by undergraduate medical students at the time of graduation identified by Sage Poe, Claude-Instant, and ChatGPT listed in electronic supplementary materials 4 – 6 , respectively. The identified SLOs emphasize the application of pharmacology knowledge within a clinical context, focusing on competencies needed to function independently in early residency stages. These SLOs go beyond knowledge recall and mechanisms of action to encompass competencies related to clinical problem-solving, rational prescribing, and holistic patient management. The SLOs generated require higher cognitive ability of the learner: action verbs such as demonstrate, apply, evaluate, analyze, develop, justify, recommend, interpret, manage, adjust, educate, refer, design, initiate & titrate were frequently used.

The MCQs for the pre-clerkship phase identified by Sage Poe, Claude-Instant, and ChatGPT listed in the electronic supplementary materials 7 – 9 , respectively, and those identified with the search query based on the clinical vignette in electronic supplementary materials ( 10 – 12 ).

All MCQs generated by the AIs in each of the four domains specified [mechanism of action (MOA); pharmacokinetics; adverse drug reactions (ADRs), and indications for antihypertensive drugs] are quality test items with potential content validity. The test items on MOA generated by Sage Poe included themes such as renin-angiotensin-aldosterone (RAAS) system, beta-adrenergic blockers (BB), calcium channel blockers (CCB), potassium channel openers, and centrally acting antihypertensives; on pharmacokinetics included high oral bioavailability/metabolism in liver [angiotensin receptor blocker (ARB)-losartan], long half-life and renal elimination [angiotensin converting enzyme inhibitors (ACEI)-lisinopril], metabolism by both liver and kidney (beta-blocker (BB)-metoprolol], rapid onset- short duration of action (direct vasodilator-hydralazine), and long-acting transdermal drug delivery (centrally acting-clonidine). Regarding the ADR theme, dry cough, angioedema, and hyperkalemia by ACEIs in susceptible patients, reflex tachycardia by CCB/amlodipine, and orthostatic hypotension by CCB/verapamil addressed. Clinical indications included the drug of choice for hypertensive patients with concomitant comorbidity such as diabetics (ACEI-lisinopril), heart failure and low ejection fraction (BB-carvedilol), hypertensive urgency/emergency (alpha cum beta receptor blocker-labetalol), stroke in patients with history recurrent stroke or transient ischemic attack (ARB-losartan), and preeclampsia (methyldopa).

Almost similar themes under each domain were identified by the Claude-Instant AI platform with few notable exceptions: hydrochlorothiazide (instead of clonidine) in MOA and pharmacokinetics domains, respectively; under the ADR domain ankle edema/ amlodipine, sexual dysfunction and fatigue in male due to alpha-1 receptor blocker; under clinical indications the best initial monotherapy for clinical scenarios such as a 55-year old male with Stage-2 hypertension; a 75-year-old man Stage 1 hypertension; a 35-year-old man with Stage I hypertension working on night shifts; and a 40-year-old man with stage 1 hypertension and hyperlipidemia.

As with Claude-Instant AI, ChatGPT-generated test items on MOA were mostly similar. However, under the pharmacokinetic domain, immediate- and extended-release metoprolol, the effect of food to enhance the oral bioavailability of ramipril, and the highest oral bioavailability of amlodipine compared to other commonly used antihypertensives were the themes identified. Whereas the other ADR themes remained similar, constipation due to verapamil was a new theme addressed. Notably, in this test item, amlodipine was an option that increased the difficulty of this test item because amlodipine therapy is also associated with constipation, albeit to a lesser extent, compared to verapamil. In the clinical indication domain, the case description asking “most commonly used in the treatment of hypertension and heart failure” is controversial because the options listed included losartan, ramipril, and hydrochlorothiazide but the suggested correct answer was ramipril. This is a good example to stress the importance of vetting the AI-generated MCQ by experts for content validity and to assure robust psychometrics. The MCQ on the most used drug in the treatment of “hypertension and diabetic nephropathy” is more explicit as opposed to “hypertension and diabetes” by Claude-Instant because the therapeutic concept of reducing or delaying nephropathy must be distinguished from prevention of nephropathy, although either an ACEI or ARB is the drug of choice for both indications.

It is important to align student assessment to the curriculum; in the PBL curriculum, MCQs with a clinical vignette are preferred. The modification of the query specifying the search to generate MCQs with a clinical vignette on domains specified previously gave appropriate output by all three AI platforms evaluated (Sage Poe; Claude- Instant; Chat GPT). The scenarios generated had a good clinical fidelity and educational fit for the pre-clerkship student perspective.

The errors observed with AI outputs on the A-type MCQs are summarized in Table  2 . No significant pattern was observed except that Claude-Instant© generated test items in a stereotyped format such as the same choices for all test items related to pharmacokinetics and indications, and all the test items in the ADR domain are linked to the mechanisms of action of drugs. This illustrates the importance of reviewing AI-generated test items by content experts for content validity to ensure alignment with evidence-based medicine and up-to-date treatment guidelines.

The test items generated by ChatGPT had the advantage of explanations supplied rendering these more useful for learners to support self-study. The following examples illustrate this assertion: “ A patient with hypertension is started on a medication that works by blocking beta-1 receptors in the heart (metoprolol)”. Metoprolol is a beta blocker that works by blocking beta-1 receptors in the heart, which reduces heart rate and cardiac output, resulting in a decrease in blood pressure. However, this explanation is incomplete because there is no mention of other less important mechanisms, of beta receptor blockers on renin release. Also, these MCQs were mostly recall type: Which of the following medications is known to have a significant first-pass effect? The explanation reads: propranolol is known to have a significant first pass-effect, meaning that a large portion of the drug is metabolized by the liver before it reaches systemic circulation. Losartan, amlodipine, ramipril, and hydrochlorothiazide do not have significant first-pass effect. However, it is also important to extend the explanation further by stating that the first-pass effect of propranolol does not lead to total loss of pharmacological activity because the metabolite hydroxy propranolol also has potent beta-blocking activity. Another MCQ test item had a construction defect: “A patient with hypertension is started on a medication that can cause photosensitivity. Which of the following medications is most likely responsible?” Options included: losartan, amlodipine, ramipril, hydrochlorothiazide, hydrochlorothiazide/triamterene. The explanation states that hydrochlorothiazide (HCTZ) can cause photosensitivity, which is increased sensitivity to sunlight that can cause skin rashes and sunburns. Losartan, amlodipine, ramipril, and HCTZ/triamterene are less likely to cause photosensitivity. However, it is irrational to claim that HCTZ/triamterene, one of the wrong options, is less likely to cause photosensitivity. The difficulty index of such test items is likely unacceptable in high-stake tests to make equitable psychometric decisions.

The responses from Sage Poe, Claude-Instant, and ChatGPT on guidance for standard-setting methods are listed in the electronic supplementary materials 13 – 15 . Sage Poe offered this information with the caveat that “the results of this simulation were purely hypothetical and do not reflect the actual performance of any real students”. The simulation estimates of examinees correctly answering test items ranged from 60 to 90% for the mechanism of action, 65–85% for pharmacokinetics, 60–80% for adverse reactions, and 75–90% for clinical indications of antihypertensives.

In contrast, Claude-Instant admitted that “Performing a full simulation with 100 medical students is beyond the scope of what I can do as an AI assistant. I can generate sample MCQ questions and answers, but I do not have access to a population of medical students to administer the questions. A true simulation that administers questions to real students and analyzes the results would require access to a database of medical students, a platform to deliver the questions, and code to analyze the responses. As an AI assistant, I lack these capabilities. While I cannot perform a full simulation, here are some considerations for administering MCQ questions to medical students: provide details on the purpose and instructions for the test to ensure students understand what is expected out of them; consider including some easier questions in addition to more challenging ones to boost students’ confidence and motivation; avoid ambiguous wording and ensure each question has only one unambiguously correct answer option; when analyzing results, look for questions factors that may have impacted performance, like unclear wording or answer options that are too similar. Focusing on weak questions can help improve future tests; compare performance across different student groups to identify areas where more teaching may be needed; provide detailed answer explanations and review sessions after the test to help students learn from any errors and reinforce correct concepts”. However, ChatGPT offered the simulation result estimates for the 20 MCQ on antihypertensive drugs: mechanism of action ranged from 67 to 92%, pharmacokinetics 63–86%, adverse effects 65–82%, and clinical indications 64–89%. Furthermore, it also stated that “Overall, the performance of the students was quite good, with most questions having a response rate of over 70%. However, there were some questions where the projected correct response rate was rather low, such as Question #5 (Mechanism of Action of Hydrochlorothiazide; see Electronic Supplementary Material 12 ) and Question 18 (Indications for Verapamil; see Electronic Supplementary Material 10 ). This may suggest areas where students need more focused education or review.”

We asked AI assistants to generate 20 integrated case cluster MCQs with 2 test items in each cluster with five options for undergraduate medical students in the pre-clerkship phase integrating pharmacology and physiology related to systemic hypertension with a case vignette and the responses by Sage Poe, Claude-Instant, and ChatGPT are listed in the electronic supplementary materials ( 16 – 18 ). In all instances, the test items generated had focused case descriptions in the form of a clinical vignette, and horizontal integration across the pathophysiology of hypertension and pharmacology of antihypertensive drugs. These test items mostly targeted the ‘knows (knowledge)’ or ‘knows how (competence)’ level on Miller’s pyramid and are suitable for assessing the clinical competence of pre-clerkship medical students, especially in an integrated PBL curriculum. Both the AI assistants generated excellent clinical vignettes and themes; however, most of the cluster MCQs by ChatGPT had “None of the above” as an option, which is often considered a test item construction flaw. Notwithstanding these limitations, case cluster integrated test items are valuable for learners to integrate their knowledge of different basic medical sciences and their application to clinical sciences. This integrated approach can be used for both instructional and student assessment purposes to make the course more meaningful. Indeed, one of the basic tenets of PBL is curriculum integration.

In the next query, we asked AI assistants to write integrated case cluster MCQs with 2 test items in each cluster with 5 options for undergraduate medical students at the time of graduation integrating pharmacology and physiology of hypertension with a case vignette. The responses are listed in the electronic supplementary materials 19 – 21 . Claude-Instant has provided only partial responses to both the queries. Overall, the information provided in case vignettes requires the learner to interpret the clinical information and make therapeutic decisions. Such test items are appropriate for assessing the minimum competency of medical school graduates to start internship or residency programs; these MCQs are generally comparable to test items used in USMLE Part 2. The evaluation of the integrated case cluster test items provided by all the AI platforms is summarized in Table  3 . In general, the AI outputs had at least one construction defect, and did not include all the core sub-topics to a sufficient degree.

When asked to simulate the above-generated test items to 100 undergraduate medical students at the time of graduation and provide a percentage of students who are likely to correctly answer each item, the AI assistant responded:

“ As an AI language model, I cannot simulate the responses of 100 undergraduate medical students likely to obtain the correct answer for each question. However, I can provide some general information about the difficulty level of each question based on the complexity of the concepts being tested and the level of integration between pharmacology and physiology ”.

AI assistant went on to clarify that questions that require knowledge of basic pharmacology principles, such as the mechanism of action of specific drugs, are likely to be easier for students to answer correctly. Test items that require an understanding of the physiological mechanisms underlying hypertension and correlating with symptoms are likely to be more challenging for students. The AI assistant sorted these test items into two categories accordingly. Overall, the difficulty level of the test item is based on the level of integration between pharmacology and pathophysiology. Test items that require an understanding of both pharmacological and physiological mechanisms are likely to be more challenging for students requiring a strong foundation in both pharmacology and physiology concepts to be able to correctly answer integrated case-cluster MCQs.

Short answer questions

The responses to a search query on generating SAQs appropriate to the pre-clerkship phase Sage Poe, Claude-Instant, and ChatGPT generated items are listed in the electronic supplementary materials 22 – 24 for difficult questions and 25–27 for moderately difficult questions.

It is apparent from these case vignette descriptions that the short answer question format varied. Accordingly, the scope for asking individual questions for each scenario is open-ended. In all instances, model answers are supplied which are helpful for the course instructor to plan classroom lessons, identify appropriate instructional methods, and establish rubrics for grading the answer scripts, and as a study guide for students.

We then wanted to see to what extent AI can differentiate the difficulty of the SAQ by replacing the search term “difficult” with “moderately difficult” in the above search prompt: the changes in the revised case scenarios are substantial. Perhaps the context of learning and practice (and the level of the student in the MD/medical program) may determine the difficulty level of SAQ generated. It is worth noting that on changing the search from cardiology to internal medicine rotation in Sage Poe the case description also changed. Thus, it is essential to select an appropriate AI assistant, perhaps by trial and error, to generate quality SAQs. Most of the individual questions tested stand-alone knowledge and did not require students to demonstrate integration.

The responses of Sage Poe, Claude-Instant, and ChatGPT for the search query to generate SAQs at the time of graduation are listed in the electronic supplementary materials 28 – 30 . It is interesting to note how AI assistants considered the stage of the learner while generating the SAQ. The response by Sage Poe is illustrative for comparison. “You are a newly graduated medical student who is working in a hospital” versus “You are a medical student in your pre-clerkship.”

Some questions were retained, deleted, or modified to align with competency appropriate to the context (Electronic Supplementary Materials 28 – 30 ). Overall, the test items at both levels from all AI platforms were technically accurate and thorough addressing the topics related to different disciplines (Table  3 ). The differences in learning objective transition are summarized in Table  4 . A comparison of learning objectives revealed that almost all objectives remained the same except for a few (Table  5 ).

A similar trend was apparent with test items generated by other AI assistants, such as ChatGPT. The contrasting differences in questions are illustrated by the vertical integration of basic sciences and clinical sciences (Table  6 ).

Taken together, these in-depth qualitative comparisons suggest that AI assistants such as Sage Poe and ChatGPT consider the learner’s stage of training in designing test items, learning outcomes, and answers expected from the examinee. It is critical to state the search query explicitly to generate quality output by AI assistants.

The OSPE test items generated by Claude-Instant and ChatGPT appropriate to the pre-clerkship phase (without mentioning “appropriate instructions for the patients”) are listed in the electronic supplementary materials 31 and 32 and with patient instructions on the electronic supplementary materials 33 and 34 . For reasons unknown, Sage Poe did not provide any response to this search query.

The five OSPE items generated were suitable to assess the prescription writing competency of pre-clerkship medical students. The clinical scenarios identified by the three AI platforms were comparable; these scenarios include patients with hypertension and impaired glucose tolerance in a 65-year-old male, hypertension with chronic kidney disease (CKD) in a 55-year-old woman, resistant hypertension with obstructive sleep apnea in a 45-year-old man, and gestational hypertension at 32 weeks in a 35-year-old (Claude-Instant AI). Incorporating appropriate instructions facilitates the learner’s ability to educate patients and maximize safe and effective therapy. The OSPE item required students to write a prescription with guidance to start conservatively, choose an appropriate antihypertensive drug class (drug) based on the patients’ profile, specifying drug name, dose, dosing frequency, drug quantity to be dispensed, patient name, date, refill, and caution as appropriate, in addition to prescribers’ name, signature, and license number. In contrast, ChatGPT identified clinical scenarios to include patients with hypertension and CKD, hypertension and bronchial asthma, gestational diabetes, hypertension and heart failure, and hypertension and gout (ChatGPT). Guidance for dosage titration, warnings to be aware, safety monitoring, and frequency of follow-up and dose adjustment. These test items are designed to assess learners’ knowledge of P & T of antihypertensives, as well as their ability to provide appropriate instructions to patients. These clinical scenarios for writing prescriptions assess students’ ability to choose an appropriate drug class, write prescriptions with proper labeling and dosing, reflect drug safety profiles, and risk factors, and make modifications to meet the requirements of special populations. The prescription is required to state the drug name, dose, dosing frequency, patient name, date, refills, and cautions or instructions as needed. A conservative starting dose, once or twice daily dosing frequency based on the drug, and instructions to titrate the dose slowly if required.

The responses from Claude-Instant and ChatGPT for the search query related to generating OSPE test items at the time of graduation are listed in electronic supplementary materials 35 and 36 . In contrast to the pre-clerkship phase, OSPEs generated for graduating doctors’ competence assessed more advanced drug therapy comprehension. For example, writing a prescription for:

(1) A 65-year- old male with resistant hypertension and CKD stage 3 to optimize antihypertensive regimen required the answer to include starting ACEI and diuretic, titrating the dosage over two weeks, considering adding spironolactone or substituting ACEI with an ARB, and need to closely monitor serum electrolytes and kidney function closely.

(2) A 55-year-old woman with hypertension and paroxysmal arrhythmia required the answer to include switching ACEI to ARB due to cough, adding a CCB or beta blocker for rate control needs, and adjusting the dosage slowly and monitoring for side effects.

(3) A 45-year-old man with masked hypertension and obstructive sleep apnea require adding a centrally acting antihypertensive at bedtime and increasing dosage as needed based on home blood pressure monitoring and refer to CPAP if not already using one.

(4) A 75-year-old woman with isolated systolic hypertension and autonomic dysfunction to require stopping diuretic and switching to an alpha blocker, upward dosage adjustment and combining with other antihypertensives as needed based on postural blood pressure changes and symptoms.

(5) A 35-year-old pregnant woman with preeclampsia at 29 weeks require doubling methyldopa dose and consider adding labetalol or nifedipine based on severity and educate on signs of worsening and to follow-up immediately for any concerning symptoms.

These case scenarios are designed to assess the ability of the learner to comprehend the complexity of antihypertensive regimens, make evidence-based regimen adjustments, prescribe multidrug combinations based on therapeutic response and tolerability, monitor complex patients for complications, and educate patients about warning signs and follow-up.

A similar output was provided by ChatGPT, with clinical scenarios such as prescribing for patients with hypertension and myocardial infarction; hypertension and chronic obstructive pulmonary airway disease (COPD); hypertension and a history of angina; hypertension and a history of stroke, and hypertension and advanced renal failure. In these cases, wherever appropriate, pharmacotherapeutic issues like taking ramipril after food to reduce side effects such as giddiness; selection of the most appropriate beta-blocker such as nebivolol in patients with COPD comorbidity; the importance of taking amlodipine at the same time every day with or without food; preference for telmisartan among other ARBs in stroke; choosing furosemide in patients with hypertension and edema and taking the medication with food to reduce the risk of gastrointestinal adverse effect are stressed.

The AI outputs on OSPE test times were observed to be technically accurate, thorough in addressing core sub-topics suitable for the learner’s level and did not have any construction defects (Table  3 ). Both AIs provided the model answers with explanatory notes. This facilitates the use of such OSPEs for self-assessment by learners for formative assessment purposes. The detailed instructions are helpful in creating optimized therapy regimens, and designing evidence-based regimens, to provide appropriate instructions to patients with complex medical histories. One can rely on multiple AI sources to identify, shortlist required case scenarios, and OSPE items, and seek guidance on expected model answers with explanations. The model answer guidance for antihypertensive drug classes is more appropriate (rather than a specific drug of a given class) from a teaching/learning perspective. We believe that these scenarios can be refined further by providing a focused case history along with relevant clinical and laboratory data to enhance clinical fidelity and bring a closer fit to the competency framework.

In the present study, AI tools have generated SLOs that comply with the current principles of medical education [ 15 ]. AI tools are valuable in constructing SLOs and so are especially useful for medical fraternities where training in medical education is perceived as inadequate, more so in the early stages of their academic career. Data suggests that only a third of academics in medical schools have formal training in medical education [ 16 ] which is a limitation. Thus, the credibility of alternatives, such as the AIs, is evaluated to generate appropriate course learning outcomes.

We observed that the AI platforms in the present study generated quality test items suitable for different types of assessment purposes. The AI-generated outputs were similar with minor variation. We have used generative AIs in the present study that could generate new content from their training dataset [ 17 ]. Problem-based and interactive learning approaches are referred to as “bottom-up” where learners obtain first-hand experience in solving the cases first and then indulge in discussion with the educators to refine their understanding and critical thinking skills [ 18 ]. We suggest that AI tools can be useful for this approach for imparting the core knowledge and skills related to Pharmacology and Therapeutics to undergraduate medical students. A recent scoping review evaluating the barriers to writing quality test items based on 13 studies has concluded that motivation, time constraints, and scheduling were the most common [ 19 ]. AI tools can be valuable considering the quick generation of quality test items and time management. However, as observed in the present study, the AI-generated test items nevertheless require scrutiny by faculty members for content validity. Moreover, it is important to train faculty in AI technology-assisted teaching and learning. The General Medical Council recommends taking every opportunity to raise the profile of teaching in medical schools [ 20 ]. Hence, both the academic faculty and the institution must consider investing resources in AI training to ensure appropriate use of the technology [ 21 ].

The AI outputs assessed in the present study had errors, particularly with A-type MCQs. One notable observation was that often the AI tools were unable to differentiate the differences between ACEIs and ARBs. AI platforms access several structured and unstructured data, in addition to images, audio, and videos. Hence, the AI platforms can commit errors due to extracting details from unauthenticated sources [ 22 ] created a framework identifying 28 factors for reconstructing the path of AI failures and for determining corrective actions. This is an area of interest for AI technical experts to explore. Also, this further iterates the need for human examination of test items before using them for assessment purposes.

There are concerns that AIs can memorize and provide answers from their training dataset, which they are not supposed to do [ 23 ]. Hence, the use of AIs-generated test items for summative examinations is debatable. It is essential to ensure and enhance the security features of AI tools to reduce or eliminate cross-contamination of test items. Researchers have emphasized that AI tools will only reach their potential if developers and users can access full-text non-PDF formats that help machines comprehend research papers and generate the output [ 24 ].

AI platforms may not always have access to all standard treatment guidelines. However, in the present study, it was observed that all three AI platforms generally provided appropriate test items regarding the choice of medications, aligning with recommendations from contemporary guidelines and standard textbooks in pharmacology and therapeutics. The prompts used in the study were specifically focused on the pre-clerkship phase of the undergraduate medical curriculum (and at the time of their graduation) and assessed fundamental core concepts, which were also reflected in the AI outputs. Additionally, the recommended first-line antihypertensive drug classes have been established for several decades, and information regarding their pharmacokinetics, ADRs, and indications is well-documented in the literature.

Different paradigms and learning theories have been proposed to support AI in education. These paradigms include AI- directed (learner as recipient), AI-supported (learner as collaborator), and AI-empowered (learner as leader) that are based on Behaviorism, Cognitive-Social constructivism, and Connectivism-Complex adaptive systems, respectively [ 25 ]. AI techniques have potential to stimulate and advance instructional and learning sciences. More recently a three- level model that synthesizes and unifies existing learning theories to model the roles of AIs in promoting learning process has been proposed [ 26 ]. The different components of our study rely upon these paradigms and learning theories as the theoretical underpinning.

Strengths and limitations

To the best of our knowledge, this is the first study evaluating the utility of AI platforms in generating test items related to a discipline in the undergraduate medical curriculum. We have evaluated the AI’s ability to generate outputs related to most types of assessment in the undergraduate medical curriculum. The key lessons learnt for improving the AI-generated test item quality from the present study are outlined in Table  7 . We used a structured framework for assessing the content validity of the test items. However, we have demonstrated using a single case study (hypertension) as a pilot experiment. We chose to evaluate anti-hypertensive drugs as it is a core learning objective and one of the most common disorders relevant to undergraduate medical curricula worldwide. It would be interesting to explore the output from AI platforms for other common (and uncommon/region-specific) disorders, non-/semi-core objectives, and disciplines other than Pharmacology and Therapeutics. An area of interest would be to look at the content validity of the test items generated for different curricula (such as problem-based, integrated, case-based, and competency-based) during different stages of the learning process. Also, we did not attempt to evaluate the generation of flowcharts, algorithms, or figures for generating test items. Another potential area for exploring the utility of AIs in medical education would be repeated procedural practices such as the administration of drugs through different routes by trainee residents [ 27 ]. Several AI tools have been identified for potential application in enhancing classroom instructions and assessment purposes pending validation in prospective studies [ 28 ]. Lastly, we did not administer the AI-generated test items to students and assessed their performance and so could not comment on the validity of test item discrimination and difficulty indices. Additionally, there is a need to confirm the generalizability of the findings to other complex areas in the same discipline as well as in other disciplines that pave way for future studies. The conceptual framework used in the present study for evaluating the AI-generated test items needs to be validated in a larger population. Future studies may also try to evaluate the variations in the AI outputs with repetition of the same queries.

Notwithstanding ongoing discussions and controversies, AI tools are potentially useful adjuncts to optimize instructional methods, test blueprinting, test item generation, and guidance for test standard-setting appropriate to learners’ stage in the medical program. However, experts need to critically review the content validity of AI-generated output. These challenges and caveats are to be addressed before the use of widespread use of AIs in medical education can be advocated.

Data availability

All the data included in this study are provided as Electronic Supplementary Materials.

Tolsgaard MG, Pusic MV, Sebok-Syer SS, Gin B, Svendsen MB, Syer MD, Brydges R, Cuddy MM, Boscardin CK. The fundamentals of Artificial Intelligence in medical education research: AMEE Guide 156. Med Teach. 2023;45(6):565–73.

Article   Google Scholar  

Sriwastwa A, Ravi P, Emmert A, Chokshi S, Kondor S, Dhal K, Patel P, Chepelev LL, Rybicki FJ, Gupta R. Generative AI for medical 3D printing: a comparison of ChatGPT outputs to reference standard education. 3D Print Med. 2023;9(1):21.

Azer SA, Guerrero APS. The challenges imposed by artificial intelligence: are we ready in medical education? BMC Med Educ. 2023;23(1):680.

Masters K. Ethical use of Artificial Intelligence in Health Professions Education: AMEE Guide 158. Med Teach. 2023;45(6):574–84.

Nagi F, Salih R, Alzubaidi M, Shah H, Alam T, Shah Z, Househ M. Applications of Artificial Intelligence (AI) in Medical Education: a scoping review. Stud Health Technol Inf. 2023;305:648–51.

Google Scholar  

Mehta N, Harish V, Bilimoria K, et al. Knowledge and attitudes on artificial intelligence in healthcare: a provincial survey study of medical students. MedEdPublish. 2021;10(1):75.

Mir MM, Mir GM, Raina NT, Mir SM, Mir SM, Miskeen E, Alharthi MH, Alamri MMS. Application of Artificial Intelligence in Medical Education: current scenario and future perspectives. J Adv Med Educ Prof. 2023;11(3):133–40.

Garg T. Artificial Intelligence in Medical Education. Am J Med. 2020;133(2):e68.

Matheny ME, Whicher D, Thadaney IS. Artificial intelligence in health care: a report from the National Academy of Medicine. JAMA. 2020;323(6):509–10.

Sage Poe. Available at: https://poe.com/Assistant (Accessed on. 3rd June 2023).

Claude-Instant: Available at: https://poe.com/Claude-instant (Accessed on 3rd. June 2023).

ChatGPT: Available at: https://poe.com/ChatGPT (Accessed on 3rd. June 2023).

James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–20.

Eschenhagen T. Treatment of hypertension. In: Brunton LL, Knollmann BC, editors. Goodman & Gilman’s the pharmacological basis of therapeutics. 14th ed. New York: McGraw Hill; 2023.

Shabatura J. September. Using Bloom’s taxonomy to write effective learning outcomes. https://tips.uark.edu/using-blooms-taxonomy/ (Accessed on 19th 2023).

Trainor A, Richards JB. Training medical educators to teach: bridging the gap between perception and reality. Isr J Health Policy Res. 2021;10(1):75.

Boscardin C, Gin B, Golde PB, Hauer KE. ChatGPT and generative artificial intelligence for medical education: potential and opportunity. Acad Med. 2023. https://doi.org/10.1097/ACM.0000000000005439 . (Published ahead of print).

Duong MT, Rauschecker AM, Rudie JD, Chen PH, Cook TS, Bryan RN, Mohan S. Artificial intelligence for precision education in radiology. Br J Radiol. 2019;92(1103):20190389.

Karthikeyan S, O’Connor E, Hu W. Barriers and facilitators to writing quality items for medical school assessments - a scoping review. BMC Med Educ. 2019;19(1):123.

Developing teachers and trainers in undergraduate medical education. Advice supplementary to Tomorrow’s Doctors. (2009). https://www.gmc-uk.org/-/media/documents/Developing_teachers_and_trainers_in_undergraduate_medical_education___guidance_0815.pdf_56440721.pdf (Accessed on 19th September 2023).

Cooper A, Rodman A. AI and Medical Education - A 21st-Century Pandora’s Box. N Engl J Med. 2023;389(5):385–7.

Chanda SS, Banerjee DN. Omission and commission errors underlying AI failures. AI Soc. 2022;17:1–24.

Narayanan A, Kapoor S. ‘GPT-4 and Professional Benchmarks: The Wrong Answer to the Wrong Question’. Substack newsletter. AI Snake Oil (blog). https://aisnakeoil.substack.com/p/gpt-4-and-professional-benchmarks (Accessed on 19th September 2023).

Brainard J. November. As scientists face a flood of papers, AI developers aim to help. Science, 21 2023. doi.10.1126/science.adn0669.

Ouyang F, Jiao P. Artificial intelligence in education: the three paradigms. Computers Education: Artif Intell. 2021;2:100020.

Gibson D, Kovanovic V, Ifenthaler D, Dexter S, Feng S. Learning theories for artificial intelligence promoting learning processes. Br J Edu Technol. 2023;54(5):1125–46.

Guerrero DT, Asaad M, Rajesh A, Hassan A, Butler CE. Advancing Surgical Education: the Use of Artificial Intelligence in Surgical Training. Am Surg. 2023;89(1):49–54.

Lee S. AI tools for educators. EIT InnoEnergy Master School Teachers Conference. 2023. https://www.slideshare.net/ignatia/ai-toolkit-for-educators?from_action=save (Accessed on 24th September 2023).

Download references

Author information

Authors and affiliations.

Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain

Kannan Sridharan & Reginald P. Sequeira

You can also search for this author in PubMed   Google Scholar

Contributions

RPS– Conceived the idea; KS– Data collection and curation; RPS and KS– Data analysis; RPS and KS– wrote the first draft and were involved in all the revisions.

Corresponding author

Correspondence to Kannan Sridharan .

Ethics declarations

Ethics approval and consent to participate.

Not applicable as neither there was any interaction with humans, nor any personal data was collected in this research study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Sridharan, K., Sequeira, R.P. Artificial intelligence and medical education: application in classroom instruction and student assessment using a pharmacology & therapeutics case study. BMC Med Educ 24 , 431 (2024). https://doi.org/10.1186/s12909-024-05365-7

Download citation

Received : 26 September 2023

Accepted : 28 March 2024

Published : 22 April 2024

DOI : https://doi.org/10.1186/s12909-024-05365-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Medical education
• Pharmacology
• Therapeutics

BMC Medical Education

ISSN: 1472-6920

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Advertisement

Supported by

Sleep Apnea Reduced in People Who Took Weight-Loss Drug, Eli Lilly Reports

The company reported results of clinical trials involving Zepbound, an obesity drug in the same class as Novo Nordisk’s Wegovy.

• Share full article

By Gina Kolata

The pharmaceutical manufacturer Eli Lilly announced on Wednesday that its obesity drug tirzepatide, or Zepbound, provided considerable relief to overweight or obese people who had obstructive sleep apnea, or episodes of stopped breathing during sleep.

The results, from a pair of yearlong clinical trials, could offer a new treatment option for some 20 million Americans who have been diagnosed with moderate to severe obstructive sleep apnea. Most people with the condition do not realize they have it, according to the drug manufacturer. People with sleep apnea struggle to get enough sleep, and they face an increased risk for high blood pressure, heart disease, diabetes, strokes and dementia.

The study’s findings have not been published in a peer-reviewed medical journal. Eli Lilly provided only a summary of its results — companies are required to announce such findings that can affect their stock price as soon as they get them. Dr. Daniel M. Skovronsky, Eli Lilly’s chief scientific officer, said the company was still analyzing the data and would provide detailed results at the American Diabetes Association’s 84th Scientific Sessions in June.

But experts not affiliated with Eli Lilly or involved in its studies were encouraged by the summary.

“That’s awesome,” said Dr. Henry Klar Yaggi, director of the Yale Centers for Sleep Medicine in New Haven, Conn.

He added that the most common treatment, a CPAP machine that forces air into the airway, keeping it open during sleep, is effective. About 60 percent of patients who use continuous positive airway pressure continue to use it, he said.

Dr. Eric Landsness, a sleep medicine researcher at Washington University in St. Louis, said the Lilly results were “phenomenal.”

They suggest, he said, that tirzepatide “is a great alternative for people who are obese and can’t use CPAP or are on CPAP and want to improve the effect.”

He added that unlike current treatments that address only the symptoms of sleep apnea, cessation of breathing, tirzepatide goes after the underlying cause, the blockages in the airway that make a person stop breathing.

Tirzepatide, sold under the brand name Zepbound, was approved by the Food and Drug Administration for weight loss in November. The agency previously approved the drug for diabetes under the name Mounjaro. Tirzepatide is part of the class of GLP-1 drugs that includes Ozempic and Wegovy, which are sold by Novo Nordisk.

Patients who participated in these Eli Lilly trials were overweight or obese and had moderate to severe obstructive sleep apnea, with moderate defined as stopped breathing at least 15 times an hour during sleep. The trials did not involve those with central sleep apnea, a type that occurs because the brain stops signaling the muscles that control breathing.

One of the Lilly studies involved about 200 people with obesity who could not or were unwilling to use a CPAP machine. Half were randomly assigned to tirzepatide, a weekly injection. The others got a placebo.

Those who got tirzepatide had an average of 27.4 fewer apnea events per hour compared with an average reduction of 4.8 events per hour for placebo.

The other Lilly trial involved about 200 people with obesity who used a CPAP machine and were encouraged to continue using it except for the assessments of their apnea episodes. Those who took tirzepatide had an average of 30.4 fewer events per hour after a year of the drug, compared with an average reduction of six events per hour for participants who got a placebo.

In both studies, participants who took tirzepatide lost about 20 percent of their weight. Dr. Skovronsky of Eli Lilly attributed the results to the loss of fat deposits in the tongue and airway.

Many people with obesity, Dr. Landsness explained, have fat deposits in the tongue and in the back of the throat. The neck gets larger with fat that narrows the airway, and the tongue gets larger in all directions, “like blowing up a balloon,” he said. During sleep, the tongue obstructs the flow of oxygen, repeatedly waking the person.

Researchers assumed that losing weight would reduce obstructive sleep apnea episodes. But before the new drugs like tirzepatide, significant and permanent weight loss was all but impossible for most people with obesity unless they had bariatric surgery.

Marishka Brown, director of the federally funded National Center on Sleep Disorders Research, said it had been difficult to know how much of an effect weight loss would have on people with sleep apnea.

“Sometimes the sleep apnea goes away, but not always,” Dr. Brown said.

For that reason, she added, when asked if weight loss is an effective treatment, “the research community has been a bit cautious about saying yes or no.”

Now, with the new results, that tentativeness may change, researchers said.

Of course, everyone in the study was eligible for tirzepatide anyway — it is approved for people with obesity, meaning those with a body mass index of at least 30, or for those with a body mass index of at least 27 and with obesity-related medical conditions.

But insurance companies do not always pay for tirzepatide for weight loss. The drug’s list price is about $1,000 a month, but insurers pay much less . Eli Lilly sells the drug to people without insurance for $550 a month.

Dr. Skovronsky said that Eli Lilly planned to submit an application to the F.D.A. and to drug regulatory agencies around the world requesting that tirzepatide be approved for the reduction of sleep apnea in people with obesity or who are overweight.

“The goal is for insurance to cover it,” Dr. Skovronsky said.

Gina Kolata reports on diseases and treatments, how treatments are discovered and tested, and how they affect people. More about Gina Kolata

A Close Look at Weight-Loss Drugs

A Company Remakes Itself: Novo Nordisk’s factories work nonstop turning out Ozempic and Wegovy, its blockbuster weight-loss drugs , but the Danish company has far bigger ambitions.

Transforming a Small Danish Town: In Kalundborg, population under 17,000, Novo Nordisk is making huge investments to increase production  of Ozempic and Wegovy.

Ozempic’s Inescapable Jingle: The diabetes drug has become a phenomenon, and “Oh, oh, oh, Ozempic!” — a takeoff of the Pilot song “Magic”  — has played a big part in its story.

The Era of ‘Brozempic’: Some telehealth start-ups are playing up masculine stereotypes to market GLP-1s  — the revolutionary class of drugs like Ozempic — which have been more widely associated with women.

Taking on Weight Stigma: Oprah Winfrey, a prominent figure in the conversation about dieting and weight bias, tackled the rise of weight loss drugs in a new prime-time special . In December, she shared that she was taking a medication to manage her weight.

Beyond Weight Loss: Wegovy is now approved for a new use: reducing the risk of heart attacks , strokes and cardiovascular-related death in adults who have heart disease and are overweight