Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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1014 — Telemedicine Cardiovascular Risk Reduction in Veterans: The CITIES trial

Lead/Presenter: Hayden Bosworth, COIN - Durham
All Authors: Bosworth HB (Durham COIN) Olsen MK (Durham COIN) McCant F (Durhham COIN) Stechuchak K (Durham COIN) Danus S (Durham COIN) Crowley MJ (Durham COIN) Goldsteiin KM (Durham COIN) Zullig LL (Durham COIN) Oddone EZ (Durham COIN)

Objectives:
Comprehensive programs addressing tailored patient self-management and pharmacotherapy may reduce barriers to cardiovascular disease (CVD) risk reduction. The role of clinical pharmacist specialists (CPS) requires further evaluation in PACT settings as well as the role of CPSs supporting multi-faceted CVD self-management programs is unclear.

Methods:
Two-arm (clinical pharmacist specialist (CPS)-delivered, telehealth intervention and usual care) randomized controlled trial including Veterans with poorly-controlled hypertension and/or hypercholesterolemia. Primary outcome was improvement in CVD risk at 6 and 12 months, with systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, low-density lipoprotein (LDL) as secondary outcomes.

Results:
Among 428 Veterans, 50% were African American, 15% were women, and 33% had limited health literacy. Relative to usual care, the CPS-delivered intervention did not show a reduction in CVD risk at 6 months (-1.8%, 95% CI: -3.9, 0.3; p = 0.10) or 12 months (-0.3%, 95% CI: -2.4, 1.7; p = 0.75). No differences were seen in SBP, DBP, LDL at 6 or 12 months. We did observe a significant decline in total cholesterol at 6 months (p = 0.03) in the intervention relative to usual care. .Among patients in the intervention group, only 34% received at least 5 of the 12 planned intervention calls and were considered "adherers". A sensitivity analysis of the complier average causal effect showed a mean difference in CVD risk reduction of -5.7% (95% CI -12.0, 0.7) at 6 months and -1.7% (95% CI: -7.6, 4.8) at 12 months among "compliers" in the intervention group compared to the control group.

Implications:
Despite increased access to pharmacist resources, in a sample of Veterans, overall, we did not observe significant improvements in CVD risk over 12 months. However, the intervention may have positive impact among those who actively participate, particularly in the short-term (e.g., 6 months).

Impacts:
There continues to be a need to simultaneously address access to care issues in the VA as well as clinical inertia, the phenomenon of providers failing to intensify medication regimens at encounters with patients who have uncontrolled risk factors. Thus, a telephone-based pharmacy intervention may be an efficacious intervention delivered remotely to patients for chronic disease healthcare (e.g., for those engaging, a 5% decrease in 10% year mortality at 6 ); however, we need to consider further how to match individuals' needs with available resources effectively.