Survey Regarding Provisions of a 3-Day Supply of an Antihypertensive

Introduction

Pharmacists must make professionally sound decisions that impact patients, the profession, and ultimately public health. Many of these decisions have legal standings that improve patient safety, provide uniformity for the practice, and promote efficiency within each setting. Unfortunately, there are situations that are not completely outlined by the law. One area that is not completely captured in the law is the duty of a pharmacist when providing a 72-hour supply of a nonschedule II prescribed medication.

Federal law mandates that a 72-hour supply of a prescribed medication be given when the medication is needed, and there is no readily available way to receive prior authorization. ^1,2 Florida Statute 465.0275 addresses that a 72-hour supply should be given as a 1-time refill of a prescribed medication, excluding schedule II medications, in the absence of an emergency. ^3,4 According to the 2005 National Ambulatory Care prescribing data, the most frequently prescribed medications include antihypertensives, antidepressants, antiasthmatics, hyperlipidemics, and antiarthritics. These classes of medications are used for chronic conditions, which require long-term medication adherence and evaluation of patient outcomes in the effort to improve the health and wellness of each patient. ⁵ However, the process of evaluating a patient’s need for a 72-hour supply is left to the professional judgment of the pharmacist.

The role of the pharmacist involves being the last health care professional a patient sees in an outpatient setting prior to administering a medication. The question becomes, “How are medication adherence and patient outcomes being evaluated by pharmacists when providing the 72-hour supply of medications?” There are currently no guidelines or laws in effect that establish a protocol to answer this question. Without any guidelines or laws to address this area of practice, each pharmacist has the authority to decide what is best for his or her setting. Therefore, evaluating the current provisions of pharmacists when providing 72-hour supplies of antihypertensives is a groundbreaking effort toward answering the above-mentioned question.

The primary objective of this study was to determine what provisions were being made by pharmacists in community settings when providing a 72-hour supply of prescribed antihypertensives. The secondary objective was to determine what provisions pharmacy interns and technicians have witnessed pharmacists making when providing the 72-hour supply of prescribed antihypertensives. These findings can open the conversation about what a pharmacist’s duties should be in these situations while presenting evidence in the matter.

Methodology

A 5-question survey was created targeting aspects that may be deemed useful in the dispensing process of a 3-day “emergency” supply of an antihypertensive. The survey did not ask the participants for any personal information, but each of the surveys asked whether the participant was a pharmacist, pharmacy intern, or pharmacy technician. The pharmacies targeted were those in community settings such as chain drug stores, independent pharmacies, and grocery store pharmacies. The objective of the study was to assess the current provisions of pharmacists while dispensing an emergency supply of an antihypertensive. Pharmacy interns and technicians were included as a means of confirmation to the responses provided by the pharmacists. The goal of the study was to attain 50 completed surveys from the pharmacists and 50 from nonpharmacists (interns or technicians) for a total of at least 100 surveys. Surveys were taken in the pharmacy where the pharmacists and nonpharmacists were employed, and the surveys were completed at the pharmacies by the participants. Prior to the completion of the surveys, participants were handed a written consent form outlining the aspects of the study and inclusion criteria. Those participants who refused to participate were not asked to complete the survey and were not included in the study results.

Results

A total of 112 participants (50 pharmacists, 41 technicians, and 21 interns) were included in this study. Each participant answered all of the survey questions completely (Appendix A). Of the 50 surveyed pharmacists, 46 (92%) have dispensed an emergency supply of an antihypertensive medication, and only 49 (79%) of the 62 surveyed nonpharmacists witnessed the dispensing of an emergency supply of an antihypertensive medication. The majority (98%) of pharmacists reported having blood pressure machines to test patients’ blood pressures at the time of dispensing the emergency antihypertensive medication. Of the 49 nonpharmacists, only 40 (82%) reported the pharmacist had access to a blood pressure machine at the time of dispensing (Appendix B). Nevertheless, most pharmacists (78%) and nonpharmacists (72%) reported that blood pressure was not checked despite the availability of a blood pressure machine (Figure 1).

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Figure 1.

Was the patient’s blood pressure checked by the pharmacist when receiving an emergency supply of an antihypertensive medication?

There was also a significant difference in the percentage of pharmacists and nonpharmacists opinions as to whether pharmacists should check blood pressure before dispensing an emergency supply of an antihypertensive medication. More nonpharmacists (66%) versus pharmacists (32%) thought pharmacists should check blood pressure before dispensing an emergency supply of an antihypertensive medication (Figure2). Only 43% of pharmacists and 69% of nonpharmacists reported that the patient was counseled and/or assessed at the time of dispensing (Figure 3).

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Figure 2.

Should pharmacists check blood pressure before dispensing an emergency supply of antihypertensive medications?

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Figure 3.

Was the patient counseled and/or assessed?

Discussion

The study did reach the targeted amount of surveys from both the pharmacists and the nonpharmacists. The results from the study provided insight into the areas that do not have clear guidelines or statutes to govern how pharmacists should intervene in patient care when patients are requesting an “emergency” 72-hour supply. Those pharmacists in the community settings encounter a variety of patients with differing needs. Hypertension is a prevalent condition, and blood pressure monitoring is an objective indicator in assessment. Patients are encouraged not to take their medications based on how they feel, but patients should take their medications as prescribed in addition to lifestyle modifications. Patients should be adequately counseled about their disease states in general. Patient counseling is a vital component in the medication use process that provides pharmacists the opportunity to probe for information necessary to enhance patient care and provide optimal outcomes. As a chronic condition, hypertension management warrants such precautions as suggested in this study to improve the quantity and quality of life for the patients.

A startling aspect of this study was patient counseling responses. More nonpharmacists reported patient counseling or assessment than the pharmacists accounted for. These results alone warrant further investigation to determine consultation practices among community pharmacies. A retrospective study design may have contributed some bias. An additional confounder could be recall bias by all pharmacy personnel that completed the survey.

This study was not designed to examine why the answers were so divided regarding whether a pharmacist should check a patient’s blood pressure prior to dispensing an antihypertensive medication, it was however predicted that division would exist since this provision is not required. It is also disconcerting as to why pharmacists did not check the patients’ blood pressure when blood pressure machines were available. With blood pressure being a quick form of objective data that could be assessed at the time of dispensing, it seems to be a source of patient assessment that is being overlooked in this situation. Although the difference between responses were not fully evaluated in this study, it is possible that the technicians were not aware of the resources the pharmacist had available. Many pharmacies may be consumed with the amount of prescriptions that need to be filled. However, it is also important to consider the impact on the patient. If a patient comes in for an emergency refill for an antihypertensive and the blood pressure reading demonstrates hypertensive urgency/emergency, refilling the prescription would not be the suggested course. These are aspects the authors would like to be taken into consideration to enhance patient care.

Conclusion

Pharmacists should exercise their professional judgment in each situation. When dispensing a 72-hour supply of a medication as defined within Florida Statue 465.0275, professional judgment should not be neglected. Antihypertensives are among the most prescribed classes of medications and require long-term patient adherence to be most effective. Patients who are out of blood pressure medications and without a readily available prescription could have uncontrolled hypertension that requires immediate attention, such as in cases of hypertensive urgency or emergency. This justifies the checking of blood pressure prior to dispensing. Otherwise, how can one know that it is time to refer the patient for emergent care?

More than half of the pharmacists who participated in this study stated that blood pressure was not checked before the dispensing of an emergency supply of an antihypertensive medication. An even greater number of pharmacists (68%) think pharmacists should not check blood pressure before dispensing an emergency supply of an antihypertensive medication. However, a similar number of technicians (66%) think the opposite. Although implications and inferences can be made about the data obtained in the survey, this survey did not allow for justification or reasons for the responses obtained. Future studies should be performed to analyze the reasons behind the responses given by pharmacists and nonpharmacists. As the affordable care act brings more patients to pharmacies, adequate consultation will be critical. Moreover, as medication therapy management becomes more prevalent, pharmacy practice will need to evolve. Most schools teach pharmacists how to take blood pressures, but there appears to be confusion as to the appropriate time to measure blood pressure in the community pharmacy setting based on these results.