Improving Depression Management in Primary Care with Collaboration

Written By : 

Susan Williams, PharmD Candidate 2015

Reviewed By :

Livia Macedo, Pharm.D.


1) Finley PR, Rens HR, Pont JT, Gess SL, Louie C, Bull SA, Bero LA. Impact of a collaborative pharmacy practice model on the treatment of depression in primary care. Am J Health Syst Pharm. 2002 Aug 15;59(16):1518-26.

Article Link:
2) Finley PR, Rens HR, Pont JT, Gess SL, Louie C, Bull SA, Lee JY, Bero LA. Impact of a collaborative care model on depression in a primary care setting: a randomized controlled trial. Pharmacotherapy. 2003 Sep;23(9):1175-85.

Article Link:

According to the World Health Organization (WHO), mental illness is purported to cause more disability than any other illnesses in developed countries, with a point prevalence of 25% in US adults and lifetime prevalence of 50%1. Recent sensational news headlines about disturbed individuals who commit violent acts toward others after being overlooked by the mental health care system have brought this public health debate to the forefront. Symptoms of depression in particular are common and may lead to significant morbidity on their own. They may also worsen outcomes of other chronic disease states. The Sertraline Anti-Depressant Heart Attack Randomized Trial (SADHART) found that long-term mortality in ACS patients was influenced by baseline depression severity and failure of sertraline to improve symptoms2. Depressed patients are more likely to present to primary care settings, perhaps due to reduced access and increased costs of specialty care from psychologists or psychiatrists, however, outcomes may be poorer. According to Bower, evidence from systematic reviews may demonstrate increased clinical effectiveness from the implementation of collaborative care models with small to medium effect sizes on health status, patient satisfaction and compliance3. However limited cost effectiveness data may point to increased costs of this model3,4. On the other hand, other studies have shown that collaboration produced better outcomes for patients with moderate to severe depression but may not be necessary or cost effective for large numbers of patients with milder symptoms that may present to primary care practitioners (PCPs)5.

The major innovation of a collaborative care model compared to either enhanced training of the primary care provider (PCP) or utilizing specialist consultation in isolation is the introduction of a care manager. A care manager takes on a significant portion of direct patient care that the PCP would normally do including assessment, patient education and care coordination with the PCP and the specialists. This model is similar to protocol-based chronic disease management systems of non-psychiatric conditions4. Psychological therapy was not associated with improved outcomes in collaborative care, but attitudes and skills of PCPs, case manager supervision by specialists and case manager mental health background did have an impact on outcomes4,6. The most important factor for effectiveness is the degree to which intervention encourages anti-depressant use among patients, which makes sense given the prominent role of medical therapy in the management of depression, particularly by PCPs4. The expertise of pharmacists with patient education and skilled medication management may improve antidepressant appropriateness and adherence6,7. According to Al-Jumah et al, interventions by pharmacists lead to improvement in patients’ adherence and a positive association exists between antidepressant adherence and improvement in depressive symptoms8.

A systematic review by Finley et al found 16 publications where pharmacist interventions for patients with mental illness improved prescribing patterns, most commonly reducing the dosage and absolute number of psychotropic drugs, even relative to psychiatrists7. In Impact of a collaborative pharmacy practice model on the treatment of depression in primary care, they implement a pilot program at Kaiser Permanente Medical Center, San Rafael, CA (KPMCSR) that attempts to improve the management of depression in primary care settings by giving clinical pharmacists a role in the management process. A collaborative care model was created in which clinical pharmacists worked at the interface between primary care and psychiatry. In an intervention group of PCPs at KPMCSR, patients who presented with depressive symptoms were prescribed antidepressant medications then referred to clinical pharmacists. The pharmacists conducted intake interviews, assessed whether patients needed immediate referral to a psychiatrist and if not, provided patient education regarding the illness, treatment with medication and medication adherence. Regular telephone encounters and clinic visits involving disease-state and medication counseling were subsequently performed and documented by the pharmacists. The pharmacists had limited prescribing privileges to modify prescribed doses and add ancillary medications. They were also in contact with the PCP to recommend changes in antidepressants if necessary. Additionally, the pharmacist was in contact and with a psychiatrist liaison at least weekly for consultation regarding patient progress. The remaining PCPs at KPMCSR who prescribed and monitored antidepressants themselves were considered a control or usual care group9.

67% of intervention patients completed the entire 6 months of the study in the collaborative model, with losses primarily due to psychiatry referral, lack of efficacy, or refusal of antidepressants. The average intervention patient began with mild to moderate depression severity and a moderate impairment in work and social functioning, which significantly improved at 6 week and 6 month timepoints when they were evaluated at clinic visits. Intervention patients had a significantly higher rate of medication adherence (15.2% more than control) and were more likely to continue antidepressant therapy beyond three months (25% more likely). They were more satisfied with their care according to their responses to post-study surveys and had a greater decrease in their resource utilization (in terms of PCP contacts in the 12 months after initiating antidepressants, a 27% difference) compared to the control patients. Although maintenance doses were similar between groups, intervention patients were more likely (18.8% more likely) to switch antidepressant medications during follow-up9.

A notable strength of this pilot study was that patients who had received counseling or antidepressants within the previous 6 months were excluded.  This study was also advantageous in that there were no significant differences in demographics or medical comorbidities between the study groups. However, the intervention group was more likely to have received antidepressants or counseling prior to this study compared to the control group, which may reflect selection bias and play a role in their adherence and the efficacy of treatment. PCPs were assigned to the intervention or control arms in a nonrandomized fashion due based on willingness to participate and clinic capacity so it cannot be assumed that the overall medical care was comparable among providers. There may have been baseline prescribing differences between intervention and control PCPs due to indirect pharmacist influence or more favorable attitudes towards the pharmacists before and during the study.  Also, depression severity and functional impairment was not assessed in the control group, therefore their improvements could only be inferred based on improvements in medication adherence9.

Immediately after completing the above pilot study, the authors followed it with a randomized controlled trial with mostly the same study population, setting and methods. This work was described in a subsequent publication Impact of a Collaborative Care Model on Depression in a Primary Care Setting: A Randomized Controlled Trial. This study corroborated the first in that there was an increase in medication adherence and reduction in PCP visits for the intervention group vs. the control group, and some statistically significant differences in satisfaction survey. Although they improved the study design by introducing randomization of PCPs to the intervention and control arms, flaws remained in the study protocol such as a lack of double-blinding. This study had less power than the previous one, leading to a decreased ability to detect statistically significant differences between the intervention and control groups10. There were questions raised about the applicability of the findings from this setting and patient demographic (large staff-model HMO with older, white, primarily female and more affluent patients with mild depression) to other settings and populations. Both studies were also too limited to adequately examine overall cost-effectiveness (such as the difference in total costs/resource utilization between the two groups, especially considering the costs of employing pharmacists and mental health specialists)9,10. Collaborative care models with expert personnel may be more costly, therefore cost-effectiveness tradeoffs may become a consideration when designing these interventions6. Determinations of cost-effectiveness have inferred both cost savings and increased costs3,4,5,7.

The authors admitted to various biases that may have been present in the trial that appear to weaken its validity but highlight positive aspects of primary care-pharmacy collaboration. Recruitment rates for study randomization diminished over time as PCPs insisted that patients receive collaborative care, likely producing selection bias. Also, the adherence rate of the control group was increased to higher than national benchmark levels in the randomized trial compared to the pilot project, which the authors attribute to possible intervention bias, as prescribing habits may have improved after clinical pharmacist services were established at KPMCSR. The Hawthorne effect was also posited10. Further studies, particularly in other settings, are needed to provide definitive evidence of the value of collaborative mental health care services provided by pharmacists in primary care but it already appears that patients and providers in this setting had recognized a benefit. The addition of pharmacists to a patient-management team may have the potential to improve patient outcomes directly and indirectly, increase patient satisfaction with their care, and improve efficiency of the use of health care resources.


  1. Reeves W, Strine T, Pratt L, Thompson W, Ahluwalia I, Dhingra S, McKnight-Eily L, Harrison L. Mental Illness Surveillance Among Adults in the Unites States. CDC WWMR 2011, 60; 1-32.
  2. Tsu L. Depression in Cardiac Patients: Underrecognized and Undertreated. US Pharmacist. 2012; 37(11): HS-12-HS-15.
  3. Bower P, Gilbody S. Managing common mental health disorders in primary care: conceptual models and evidence base. BMJ. Apr 9, 2005; 330(7495): 839–842.
  4. Bower P. Collaborative Models Between Primary Care and Specialist Services in the Management of Common Mental Health Problems. Clinical Neuropsychiatry. 2011; 4:243-251.
  5. Katon W, von Korff M, Lin E et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995; 273:1026-31.
  6. Bower P, Gilbody S, Richards D, Fletcher J, Sutton A. Collaborative care for depression in primary care. Making sense of a complex intervention: systematic review and meta-regression. The British Journal of Psychiatry (2006)189: 484-493.
  7. Finley PR, Crismon ML, Rush AJ. Evaluating the impact of pharmacists in mental health: a systematic review. Pharmacotherapy. 2003 Dec 23(12):1634-44.
  8. Al-Jumah KA, Qureshi NA. Impact of pharmacist interventions on patients’ adherence to antidepressants and patient-reported outcomes: a systematic review. Patient Prefer Adherence. 2012;6:87-100.
  9. Finley PR, Rens HR, Pont JT, Gess SL, Louie C, Bull SA, Bero LA. Impact of a collaborative pharmacy practice model on the treatment of depression in primary care. Am J Health Syst Pharm. 2002 Aug 15;59(16):1518-26.
  10. Finley PR, Rens HR, Pont JT, Gess SL, Louie C, Bull SA, Lee JY, Bero LA. Impact of a collaborative care model on depression in a primary care setting: a randomized controlled trial. Pharmacotherapy. 2003 Sep;23(9):1175-85.

Effects of Multidisciplinary Care on Residential Care Facilities: Does it Make a Difference?

Written By :

Janice Lee, PharmD Candidate 2015

Reviewed By :

Livia Macedo, Pharm.D.


Boorsma M, Frijters DH, Knol DL, Ribbe ME, Nijpels G, van Hout HP. Effects of multidisciplinary integrated care on quality of care in residential care facilities for elderly people: a cluster randomized trial. CMAJ. 2011 Aug 9;183(11):E724-32.

Article Link

In 2011 the Canadian Medical Association Journal published the: Effects of Multidisciplinary integrated care on quality of care in residential care facilities for elderly people: a cluster randomized trial1. This study was able to cite the correlation between multidisciplinary team care and the improvement of standard care for elderly individuals in residential care facilities. A randomized controlled trial involving ten residential care facilities in the Netherlands were utilized. Five of the facilities provided multidisciplinary integrated care, and five provided usual care. The intervention consisted of geriatric assessment of functional every three months. The assessment was used by trained nurse-assistants to design the guide of individual care plan; discussion of the outcomes and care priorities with the family physician, resident and the patient’s family. There were multidisciplinary meetings with the nurse-assistant, family physician, psychologist and geriatrician to discuss residents with complex needs.1

Although this study showed improved quality of care with a multidisciplinary team, this data has several limitations.  First, the patient population of the elderly is difficult to evaluate because individuals often have functional and cognitive impairments that increase over time1. Additionally, since most individuals in long-term care have various health ailments, the duration of the trial was only six months due to the high risk of drop out.

Second, the study was conducted in the Netherlands where the generalizability of results to be applicable to the United States does not necessarily apply. Long term care in the Netherlands is funded by mandatory state controlled insurance2. In contrast, long-term care in the U.S. such as residential facilities for the elderly is mostly self-financed by individuals. Thus, long-term health care in the U.S. is variable and contingent on financial cost3.

The applicability of conducting an ideal multidisciplinary team in the US health care system also remains questionable due to financial restrictions. Staffing a competent team to work together where the education level, experience and interprofessional skills of cooperation and good communication take time and depend on the individual’s themselves4. The cohesiveness of the health care team to make effective decisions depends on the infrastructure and the individual members of the team itself. Trust in professional competency and positive rapport takes time to develop in an interdisciplinary setting.

Additionally, the facility itself and the criteria of staff education and standards can differ from facility to facility. Various facilities have different policies in regards to their mix of staffing and their admittance policy for elderly individuals in need of care, as well as their discharge policies in relinquishment of care. Thus, the process of care in a multidisciplinary care team depends on cultivating a professional team in a cost-effective infrastructure.

Although this randomized control trial was major in respect to showing how multidisciplinary care can have improved outcomes, it remains to be seen whether this can be carried out on a financial and organizational level in the United States. Since many patients base their health care decisions on their financial limitations, managed care settings can be one way to resolve the heterogeneity of team members and account for the financial demands in implementing primary care4.  Conducting future clinical trials in these managed care settings in the U.S. can be one way to develop evidence for the effectiveness of multidisciplinary team based care in primary settings.



1. Boorsma M, Frijters DH, Knol DL, Ribbe ME, Nijpels G, van Hout HP.  Effects of multidisciplinary integrated care on quality of care in residential care facilities for elderly people: a cluster randomized trial. CMAJ. 2011 Aug 9;183(11):E724-32.

2. Schoen C, Osborn R, Doty M, Bishop M, Peugh J, Murukutia N.  Toward higher-performance heath systems: adults’ health care experiences in seven countries, 2007. Health Aff (Millwood). 2007 Nov-Dec;26(6):w717-34.

3.  Feder J, Komisar HL, Niefeld M. Long-term care in united states: an overview. Health Aff (Millwood). 2000 May-Jun;19(3):40-56.

4.  Boul C, Reider L, Leff B, Frick K, Boyd C, Wolff J, Frey K, Karm L, Wegener S, Mroz T, Scharfstein D. The effect of guided care teams on the use of health services, results from a cluster-randomized controlled trial. Arch Intern Med. 2011 Mar 14;171(5):460-6.





How to Improve Patients’ Experiences in Interprofessional Team Based Primary Care

Written By :

Suhl A Choi, PharmD Candidate 2015

Reviewed By :

Livia Macedo, Pharm.D.


Rodriguez HP, Roger WH, Marshall RE, et al. Multidisciplinary Primary Care Teams Effects on the Quality of Clinician-Patient Interactions and Organizational Features of Care. Medical Care. 2007;45: 19-27.


Who did you see in your last primary care visit? Your primary care physician or some other health care providers, such as a physician assistant, or a nurse practitioner?

In old days, primary care physicians (PCP) were the main health care providers in a primary health care setting. However, now many primary care settings have adopted the multidisciplinary team practice models to improve patient outcome and safety. Physician assistants, and registered nurse practitioners collaborate with primary care physicians to provide advanced patient care. Pharmacists are also considered as members of a multidisciplinary primary care team in some practices and they provide patient education on drug administration and medication safety.

According to a study “Multidisciplinary Primary Care Teams Effects on the Quality of Clinician-Patient Interactions and Organizational Features of Care” by Rodrigues et al., patients who regularly received medical care from their PCP reported higher quality physician-patient relationship compared to those who did not regularly seek medical attention from their PCP1. Those patients who frequently visited their PCP were satisfied with PCP’s communication skill, knowledge of patient, and health promotion support1. Other studies2-5 suggested that patients often did not experience additive values from a multidisciplinary team in their primary care setting and some patients did not even recognize the team1.  If this is true, then why is interprofessional team based care considered as the advanced and better practice model in primary care setting?

Many studies suggested the benefits of multidisciplinary team in primary care practice. One study argued that primary care service provided by mid-level practitioners lowered overall health care cost per patient6. It was also demonstrated that health care providers from different disciplines bring diverse knowledge and skills that were required to provide high quality comprehensive care to patients who suffer from multi-disease states7. Therefore patients will clearly benefit from multidisciplinary team based care if the team is well managed and meets the patients’ need.

In the study, Rodrigues et al., categorized teams based on their “relationality” and “visibility”1.

Relationality: strong relationship among the members of the multidisciplinary primary care team


  • Visible: non-PCP clinicians in the patients’ primary care physician’s office contributed significantly in the patient care
  • Invisible: only PCP played an important role in the patient care

Patients who reported their multidisciplinary primary care team as moderately or highly visible had more favorable experience than those who reported their team as invisible. Patients who receive care from high relationality had more favorable primary care experience than those who received care from low to moderate relationality team. Lastly, patients who seen by low relationality primary care team showed worse experience than those patients who received care from invisible team.

This study demonstrates the importance of coherence in an interprofessional primary care team. Patients will benefit from the team-based care only when the team is well organized and consistent. Unstable relationships among the multidisciplinary primary care team members can lead to discontinuity of care because patients lost the clinician-patient relationship. The result of this study also highlighted patients’ positive experience when the team is visible. Therefore, from this study, we can conclude that an interprofessional team, which all members in the team are working closely to provide the best patient care, can improve patient care and for better patient outcomes. Each member in the team will need to build a strong clinician-patient relationship so that the patient can be aware of each clinician’s contribution.

How can an interprofessional primary care team improve relationality?

The authors of the study argued that hierarchy within the team members prevented the participation of the members on the bottom of the hierarchy pyramid. This could create dissatisfaction among members and lead to unstable and poor functioning team. For this reason, a team should be built based on vertical hierarchy. This structure allows free communication between health care providers from different disciplines. All health care providers in the team have the equal opportunity to participate in patient care. Secondly, role and responsibility of each member of the team should be clearly defined as well. The role should be defined based on each health care discipline’s strength and should not be overlap with another member of the team. For example, pharmacists are the drug experts thus pharmacists can provide input on medication, such as patient counseling on drug administration, drug side effects, and drug adherence.

This article successfully demonstrated that a continuous physician- patient relationship was associated with favorable patient outcome. It also described the importance of visibility and relationality of a multidisciplinary team in order to achieve better patient satisfaction. However, this study did not explain barriers that prevent patients from regularly visiting their PCP and receiving medical care. Unfortunately, this study did not clearly explain how a multidisciplinary team could function in order to improve physician- patient relationship in a primary care setting. Identifying services, which a multidisciplinary team can provide to a patient, to improve patient’s satisfaction and health outcome would be valuable information for those health care providers who want to build a new multidisciplinary health care team.

In conclusion, current studies suggest mixed opinion regarding the importance of multidisciplinary primary care team. However, I think the interdisciplinary team based care will improve patient care in primary care setting. The success of interdisciplinary team based practice in primary care will be largely dependent on health care providers’ willingness to cooperate. I believe that the ability to work with other health care professionals from different discipline is a critical skill that all future health care providers should learn in school. As a pharmacy student, I know what I can offer to my patients and the team but I do not clearly understand the responsibility of other health care providers. This is why interprofessional education is important. Discussing each other’s role to provide the best patient care in early stage of career will increase the students’ understanding on each other’s responsibility and help to form vertical hierarchy. This will help students to learn how to improve relationality in the real world practice. This is a big homework for future health care providers to build a strong interdisciplinary team, which our patients can trust and willing to form sustained patient-clinician relationship.



1. Rodriguez HP, Roger WH, Marshall RE, et al. Multidisciplinary Primary Care Teams Effects on the Quality of Clinician-Patient Interactions and Organizational Features of Care. Medical Care. 2007;45: 19-27.

2. Safran DG, Montgomery JE, Chang H, et al. Switching doctors: predictors of voluntary disenrollment from a primary physician’s practice. J Fam Pract. 2001;50:130-136.

3. Safran DG, Tarlov AR, Rogers WH. Primary care performance in fee-for-service and prepaid health care systems. Results from the Medical Outcomes Study. JAMA. 1994; 271: 1579-1586.

4. Safran DG, Rogers WH, Tarlov AR, et al. Organizational and financial characteristics of health plans: do they affect primary care performance. J Gen Intern Med. 1998;13:66.

5. Safran DG, Wilson IB, Rogers WH, et al. Primary care quality in the Medicare Program: comparing the performance of Medicare health maintenance organizations and traditional fee-for-service medicare. Arch Intern Med. 2002; 162:757-765.

6. Robin DW, Howard DH, Becker ER, et al. Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO. Health Serv Res. 2004;39:607-626.

7. Fried BJ, Topping S, Rundall TG. Groups and teams in organizations. In: Shortell SM, Kaluzny AD, eds. Health Care Management: Organization Design and Behavior. Albany, NY: Delmar; 2000:154-190.

Physicians and Pharmacists Working Together Improves Hypertension Control

Written By :

Miguel Franquiz, PharmD Candidate 2016

Reviewed By :

Livia Macedo, Pharm.D.


Carter VL., et. al. (2009) Physician and Pharmacist Collaboration to Improve Blood Pressure Control. Internal Medicine, 169(21), 1996-2002.

Article Link

Large epidemiologic studies1,2 have shown that in the United states, a country with a high prevalence of hypertension, often more than half of these patients have uncontrolled disease. Despite national lifestyle modification efforts, a strong focus on public health literacy, and widely disseminated evaluation and treatment guidelines, hypertension control remains suboptimal.  The reasons behind such subpar control are no doubt multifactorial, and a great deal of time, effort, and resources have been focused on designing clinical strategies to improve hypertension control. One such modality incorporates team based patient care, involving a physician and a pharmacist working collaboratively. Data from primary literature clearly show significant improvement in blood pressure control following physician-pharmacist comanagement interventions.3,4,5 In an attempt to validate such findings, Carter et. al. have conducted a large, multi-center trial evaluating outcomes of physician-pharmacist comanagement of hypertension in community healthcare settings.

Physician and Pharmacist Collaboration to Improve Blood Pressure Control (PPC-BP) was a prospective, randomized , multi-center, open-label, parallel assignment, controlled trial with the goal of demonstrating improved efficacy of physician and pharmacist comanagement of hypertension over usual care.6 The primary outcome was physician adherence to hypertension guidelines, measured by a computer algorithm previously developed by the investigators7. The secondary outcomes were blood pressure control quantified by surrogate markers, physician knowledge, physician-pharmacist relationship, and patient medication adherence. The trial enrolled 623 participants and was designed with 88-100% power to detect a statistically significant difference in systolic blood pressure between treatment and control groups. All outcomes were assessed during two 6-month periods: prior to the patient’s enrollment in the trial and again while the patient was enrolled in the study.

The study included males and females older than 21 with diagnosed essential hypertension with systolic blood pressures between 140 and 179 for non-diabetes patients, and systolic blood pressures between 130 and 179 for patients with a history of diabetes. Eligible participants were randomized to one of 6 different investigation sites located in community medicine offices. Physician and pharmacist collaborative care was employed at three sites, and standard treatment at the other three. The three intervention sites also contained passive observation populations, usual care groups that served to analyze covariance within a particular investigation site.  Physicians and pharmacists at all sites underwent team building sessions and guideline adherence education prior to study interventions. Specific intervention strategies were structured and presented to physicians and pharmacists at the 3 intervention sites, but implementation was dictated by the investigators. Interventions included collaborative physician and pharmacist in-office patient visits, medication regimen reviews and reconciliation, and a 1 month follow up telephone interview completed by the pharmacist to stress medication adherence. In the usual care group, pharmacists present at community medicine offices were available to provide drug information to physicians and performed duties not above their normal employment at the office.


Table 3

Guideline adherence improved dramatically in the experimental group as compared to usual care (8.4% vs.  55.1% from baseline). Guideline adherence was not assessed for the passive observation group. Mean reduction in systolic blood pressure from baseline was also superior in the intervention group (20.7 mmHg vs. 6.8 mmHg). Systolic blood pressure reduction in the passive observation group was comparable to the active control group but was not assessed statistically per measurement reliability (trained research nurse vs. retrospective medical record audit).

Based on these results it would it appear that the improvements in hypertension control brought about by pharmacist and physician collaboration are certain, and objectively verifiable. The benefits of systolic blood pressure reduction with respect to actual clinical outcomes have been demonstrated in numerous other publications8,9. However positive this study’s results, they do carry the potential to mislead audiences, stemming from flaws in study design and implementation. First, the positive results in this study may not necessarily translate to other primary care demographics. This study assessed mostly white male participants and was skewed towards an age range of 57-63. The study population also showed little evidence of chronic hypertensive disease or end toxicities of others chronic diseases (CVA, MI, Angina, cardiovascular surgery, LVH, HF). In addition, although this study far surpasses its peers in terms of numbers of participants, larger studies are necessary to establish strong statistical support of the documented benefits. Another disadvantage of this study stems from its heterogeneity in intervention implementation. Although the authors note that physicians and pharmacists attended team building and guideline education sessions, they opted to allow individual investigators to control how the intervention was implemented at their respective sites. This introduces an element of uncertainty to the findings, and without clearly defined, uniform interventions across sites, it’s possible that this same study design may not reproduce similar results if repeated. Lastly, as the study only reports 6 month outcomes, it’s hard to say whether or not such great benefit is sustainable.

When viewing this trial in context of the litany of other publications objectively demonstrating similar improvement in hypertension control, I believe that physician-pharmacist collaboration represents a clearly effective strategy in combating the drastically high prevalence of uncontrolled hypertension in the United States. Whether such poor control is attributable to life style, clinical inertia, or any other of the many competing theories, it would seem prudent that we begin to shift our attention toward solutions. Although there are many barriers to effective collaboration in healthcare, our great focus on evidence based practice favors collaboration in the case of this poorly controlled chronic disease.


1.         Keenan NL., Rosendorf KA (2011).  Prevalence of hypertension and controlled hypertension-United States, 2005-2008. CDC MMWR 2011, 60, 94-97.

2.         Burt VL., Whelton P., Roccella EJ., et. al. (1995). Prevalence of hypertension in the US adult population results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension25(3), 305-313.

3.         Weber CA., Ernst ME., Sezate GS., et. al. (2010). Pharmacist-physician comanagement of hypertension and reduction in 24-hour ambulatory blood pressures. Archives of internal medicine170(18), 1634

4.         Tobari H., Arimoto T., Shimojo N., et. al. (2010). Physician–Pharmacist Cooperation Program for Blood Pressure Control in Patients With Hypertension: A Randomized-Controlled Trial.American Journal of Hypertension23(10), 1144-1152.

5.         Carter BL., Doucette WR., Franciscus CL., et. al. (2010). Deterioration of Blood Pressure Control After Discontinuation of a Physician‐Pharmacist Collaborative Intervention.Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy,30(3), 228-235.

6.         Carter VL., et. al. (2009) Physician and Pharmacist Collaboration to Improve Blood Pressure Control. Internal Medicine, 169(21), 1996-2002.

7.         Milchak JL., Carter  BL., Ardery G., (2006). Development of explicit criteria to measure adherence to hypertension guidelines. J Hum Hypertens. 20(6), 426-433.

8. Whelton  PK., et al. (2002) Primary prevention of hypertension. JAMA: the journal of the American Medical Association 288.15,1882-1888.

9. Guilbert JJ. (2003) The world health report 2002-reducing risks, promoting healthy life. Education For Health. 16.2, 230-230.

What Makes High IMPACT Interprofessional Teams Effective?

Check out my article about “Interprofessional Teams” recently published in iForumRx

My article was reviewed by: 

Jeannie Kim Lee, Pharm.D., BCPS, CGP
Deborah Sturpe, Pharm.D., BCPS
Tracy CS, Bell SH, Nickell LA, Charles J. The IMPACT clinic: innovative model of interprofessional primary care for elderly patients with complex health care needs. Can Fam Physician. 2013; 59(3):e148-55.

– See more at:

ASHP-Midyear Poster Presentation- Winter 2013

ASHP-Midyear Poster Presentation- Winter 2013

See my poster abstract below:

Title: Using an objective structured teaching exercise (OSTE) to develop pharmacy preceptors

Primary Author: Livia Macedo

Additional Authors:
Deborah A. Sturpe
Stuart T. Haines
Toyin Tofade
Cherokee Layson-Wolf
Mary Lynn McPherson

A potential model for preceptor development is the objective structured teaching exercise (OSTE), a unique method previously described in the medical education literature. During an OSTE, participants observe and practice clinical teaching skills and receive feedback in a low-threat environment through interaction with standardized students trained to portray specific roles. To date, there are no studies evaluating OSTE for pharmacy preceptor development. Our objective is to determine the feasibility and acceptability of the method.

The protocol was reviewed by the IRB and was deemed exempt because it involved normal instructional practices conducted in a commonly accepted educational setting. The project will consist of three phases. In Phase I, a comprehensive training needs analysis will be distributed to advanced pharmacy practice experience (APPE) community pharmacy preceptors. Data will also be collected from students’ APPE community pharmacy practice evaluations regarding the types of activities performed and value of feedback received during each rotation. These data will be used to identify topics for preceptor development that are amenable to the OSTE format. In Phase II, we will design, develop, implement, and evaluate a three-station OSTE. In Phase III, changes in preceptor behavior will be measured. This project is innovative because it will be the first to evaluate the utilization of OSTE for preceptor development in pharmacy education and to examine long-term behavioral changes.

P.S. Please let me know your thoughts and ideas about this research. Manuscript in the making…

What is The Value of Diet and Exercise in Patients With Diabetes?

Citation: The Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013; 369: 145-54.

Category: Diabetes
Original commentary found in, written by: By Danielle Hebel, PharmD and Erica Pearce, PharmD, BCPS

Today, I read this Article posted in iForumRx: “Looking AHEAD to less diet and exercise for patients with diabetes?

This article points out that intensive lifestyle interventions (7% weight loss and increase physical activity 175 min/week) does not impact CV morbidity and mortality or lower CV risk; however, it does have positive outcomes on A1C, HDL, LDL, and mean SBP.  In addition, it can lower the risk of urinary incontinence, sleep apnea, and depression, as well as improve quality of life and physical functioning.

Patients in this study were not poorly controlled with their DM as we see in practice. Perhaps in patients who are poorly controlled, intensive lifestyle interventions may lower their CV risk. This commentary questions whether weight loss and exercise should be recommended to all patients with DM. I would say YES; while, weight loss (for patients who are obese) and exercise may not truly show decrease in CV risk, it can still bring other benefits and it does not cause harm; therefore if the pt is able to exercise I would recommend it.


Personal Learning Network

Happy Friday! I really enjoyed learning about so many great tools in my EDUC689 informal learning course this summer and developed a different way of thinking about networks and informal learning. I created my personal learning network (PLN) in Pinterest because it allows me to pin anything I find interesting at anytime and organize it in different boards.

Check out my PLN here:

“My Action Plan” to keep up with my PLN will be to continue to follow and expand my network in twitter, Linkedin, and facebook. My goal is to post on my blog at least once a month on new things I am learning. It’s my duty to keep up with my readings and keep on top of information not only in the pharmacy world, but in the eLearning and instructional design world. I’ll continue to pin pin away on Pinterest as I learn more throughout life long learning and with my peers.

Thank you everyone and Thank you Jeannette Campos for a wonderful course this summer!

A Whole New Mind Book Report by Daniel Pink

During my informal learning masters course (EDUC689) I had the opportunity to read the book “A Whole New Mind” by Daniel Pink and worked together with three peers in a book report. As a group, we enjoyed reading and learning about the evolution of our society from left brain to right brain thinking. We present our book report for “A Whole New Mind” by Daniel Pink. Enjoy!

A Whole New Mind Book Report by Daniel Pink

Thoughts About the Future of Workplace Learning

After hearing what many eLearning experts have to say…various thoughts came to mind about the future of workplace learning.
First, I am not sure why students are continuously going to classrooms to listen to didactic lectures…why not start self-directed and informal learning from day 1 in high school, university, and graduate school? This method will allow students to train for real world problems and experiences.
In the real world, we have workplaces with a collaborating environment – “ideally” – where people learn by continuously performing a skill, learn via self-directed and informal learning via the internet, books, with their peers, twitter, Facebook, etc. Can we replicate this picture early on in education (e.g. could really start as early as middle school up to graduate school)?

As a student over the years, I sat through various lectures, but in some courses I really didn’t feel I had a grasp of what I had learned. After graduation, I had to learn on the job, learn by facing reality, learn by fear, learn with others (e.g. peers, mentors, personal learning network), learn by pressure, learn to save lives, and learn to teach or facilitate learning of other pupils. Finally, learning because I love to learn!
I pursued a residency and currently on a fellowship to gain more experience in my skills before transitioning into the real world in which learning is more informal and self-directed.

So, why are we not instigating active learning early on in education in our students? By skipping active learning altogether, we are really jeopardizing their learning and future professional lives by teaching them “everything they need to know for the test”, but in reality, not the truth they need to know to make it in the real world”.
So what are your thoughts on what the future of learning will look like?

You should be aware that courses from top universities such as Harvard and John Hopkins are now being offered for FREE online such as:

So what does this all mean to the world of education? I think the future of education will be students learning on their own via self-directed and informal learning because the information will be available and easily accessible everywhere.

Now, the important component will be to replicate the “real world”. I think it will be a lot more valuable if students come to school to meet as group for active learning or flipped classroom, where they will participate in TOSCEs, OSCEs, laboratory activities, team-based learning activities, problem-based learning activities, etc. Right now, most students tend to not show up to lectures, face-to-face anyways, if attendance is not required. However, these same students do show up for laboratory and group collaboration activities in order to get the hands-on-experience needed to function in the real world.

How will we “educators” assess students’ knowledge? I believe quizzes, exercises, examinations, TOSCEs, OSCEs, etc. should be a continuous process to access their knowledge on every step of the curriculum in order to prepare them to go into practice and assess if they have really learned the material or mastered a skill.

Let’s take higher education to the next level and show our students the truth about what the real world is all about early on in their education! I think building this habit and behavior of functioning independently, but yet collaborating with others along the way, early on in education, prepares one further to what’s about to come in the next phase of their lives.

Will you join me in this journey? What are your thoughts?

~Livia Macedo