SPECIAL FEATURE

Evaluation of a hypertension
medication therapy
management program in
patients with diabetes
Lourdes G. Planas, Kimberly M. Crosby, Kimberly D. Mitchell, and Kevin C. Farmer

Received October 31, 2008, and in revised

Abstract form January 6, 2009. Accepted for publica-
tion January 9, 2009.

Lourdes G. Planas, PhD, is Assistant Profes-

Objective: To evaluate the effect of a 9-month community pharmacy–based medi- sor, College of Pharmacy, University of Okla-
cation therapy management (MTM) program on quality of care in patients with diabe- homa Health Sciences Center, Oklahoma
tes and hypertension. City. Kimberly M. Crosby, PharmD, BCPS,
CGP, is Clinical Assistant Professor, College
Design: Randomized controlled trial. of Pharmacy, Schusterman Center, Univer-
Setting: Tulsa, OK, between November 2005 and July 2007. sity of Oklahoma, Tulsa, and Clinical Ser-
Patients: 52 patients with diabetes and hypertension who were enrolled in a vices Coordinator, USA Drug Stores, Tulsa,
OK. Kimberly D. Mitchell, PharmD, is Clini-
managed care organization. cal Pharmacist, USA Drug Stores, Tulsa, OK,
Intervention: During monthly visits, intervention group participants received and Assistant Professor, College of Pharma-
cy, Southwestern Oklahoma State Universi-
MTM services for hypertension and diabetes management. ty, Tulsa. Kevin C. Farmer, PhD, is Associate
Main outcome measures: Systolic blood pressure (SBP), percentage at goal Professor, College of Pharmacy, University
blood pressure (<130/80 mm Hg), and antihypertensive medication adherence. of Oklahoma Health Sciences Center, Okla-
homa City.
Results: The mean intervention group SBP decreased 17.32 mm Hg, whereas
the mean control group SBP level increased 2.73 mm Hg (P = 0.003). The percentage Correspondence: Lourdes G. Planas, PhD,
Assistant Professor, College of Pharmacy,
of patients at goal blood pressure increased from 16.0% to 48.0% in the interven- University of Oklahoma Health Sciences
tion group and decreased from 20.0% to 6.67% in the control group. Intervention Center, 1110 N. Stonewall Ave., Oklahoma
group participants were 12.92 times more likely than control group participants to City, OK 73117-1200. Fax: 405-271-6430.
E-mail: lourdes-planas@ouhsc.edu
achieve goal blood pressure (P = 0.021). Although the mean adherence rate in the in-
tervention group increased 7.0% while remaining fairly constant in the control group Disclosure: Dr. Crosby is cofunded by USA
Drug Stores, and Dr. Mitchell is employed by
(–0.7%), this group difference was not statistically significant. USA Drug Stores. The other authors declare
Conclusion: A community pharmacy–based hypertension MTM program was no conflicts of interest or financial interests
effective in improving blood pressure control among managed care enrollees with in any product or service mentioned in this
article, including grants, employment, gifts,
diabetes and hypertension. Community pharmacists are strategically positioned to stock holdings, or honoraria.
provide MTM services and effectively communicate with providers to improve quality
of care for patients. Acknowledgments: To Jennifer Moulin for
patient scheduling, Brandi Belicek for data
Keywords: Adherence, blood pressure, community pharmacy, diabetes, hyper- entry, and Jack Sommers, MD, MBA, Rhon-
tension, interventions, medication therapy management. da Holt, RN, MPA, Jason Cuaderes, BPharm,
Joe Courtright, BPharm, and Chris Kaiser,
J Am Pharm Assoc. 2009;49:164–170. BPharm, for administrative support.
doi: 10.1331/JAPhA.2009.08164
Funding: By the American Pharmacists As-
sociation Foundation, the American Society
of Health-System Pharmacists Foundation,
and USA Drug Stores.

Previous presentation: American Pharma-

cists Association Annual Meeting, Atlanta,
GA, March 18, 2007.

See related article on page 143.

164 • JAPhA • 4 9 : 2 • M a r /A p r 2009 www.j aph a. or g Journal of the American Pharmacists Association
 Hypertension MTM program in patients with diabetes SPECIAL
T
he estimated prevalence of hypertension among U.S.
adults is 29%, with approximately 50 million people in
the United States diagnosed with hypertension.1,2 The
prevalence estimates of hypertension among individuals with
diabetes vary widely, with estimates of 50% to 90% of people
diagnosed with diabetes having hypertension as a comorbidity.3
Data from the Centers for Disease Control and Prevention indi-
cate that 23.6 million people in the United States were affected
by diabetes in 2007.4 This could mean that up to 21 million peo-
ple with diabetes in the United States also had hypertension,
which is defined as a blood pressure greater than 130/80 mm
Hg or treatment with antihypertensive therapies.4–6
Because patients with diabetes and hypertension are at an
increased risk of cardiovascular complications and death, con-
trolling blood pressure is as important as maintaining glycemic
control.2,7 For every 10 mm Hg reduction in systolic blood pres-
sure (SBP), the risk of complications associated with diabe-
tes is reduced by 12%.8 However, the majority of patients with
diabetes are not at goal blood pressure. National Health and
Nutrition Examination Survey (NHANES) data published for
At a Glance
Synopsis: Blood pressure control among pa-
tients with diabetes and hypertension was effectively
improved as a result of an intervention providing hy-
pertension medication therapy management (MTM)
services during monthly visits to a community phar-
macy. Mean systolic blood pressure (SBP) among in-
tervention group participants decreased 17.32 mm
Hg, whereas that for the control group increased 2.73
mm Hg (P = 0.003). The percentage of participants at
goal blood pressure increased threefold (from 16.0%
to 48.0%) in the intervention group, while decreasing
by two-thirds among control group participants (from
20.0% to 6.67%). Intervention group participants
were 12.92 times more likely than control group par-
ticipants to achieve goal blood pressure (P = 0.021).
Analysis: Data have indicated that lowering blood
pressure significantly reduces the risks of diabetes-
related complications, yet many patients with diabetes
do not meet recommended goals for blood pressure
control. In the United Kingdom Prospective Diabetes
Study, a 10–mm Hg decrease in blood pressure reduced
the risk of cardiovascular morbidity and mortality from
stroke and myocardial infarction in patients with dia-
betes and reduced the risk of developing microvascular
complications. Community pharmacists are strategi-
cally positioned to provide MTM services and effectively
communicate with providers to improve quality of care
for patients with diabetes and hypertension. Pharma-
cists in the current study also were able to increase the
medication adherence rate among intervention group
patients by 7 percentage points (from 80.5% before
the study to 87.5% during the study period).
Journal of the American Pharmacists Association
FEATURE
2003–2004 indicated that only 48% of patients with diabetes
and hypertension had achieved a blood pressure of less than
130/80 mm Hg.6 Diabetic patients with uncontrolled hyperten-
sion may benefit from care provided by community pharmacists
to help manage their medications and blood pressure.
Previous research has indicated that community pharma-
cists can have a positive influence on outcomes for patients
with hypertension, including those with comorbid diabetes.9–13
However, studies using randomized controlled designs to dem-
onstrate the effect of pharmacist-driven medication therapy
management (MTM) on quality of care for hypertensive patients
with diabetes are lacking. Additionally, most studies have been
conducted in institutional or physician clinic settings instead
of community practice, where the majority of patients receive
care.
One intermediate outcome of MTM services is improving
patient adherence to medications. Patients often fail to take
medications as directed or may prematurely discontinue ther-
apy. This nonadherence can be especially problematic in the
successful treatment of chronic diseases. A recent review of
139 studies found that only 59% of patients took at least 80%
of cardiovascular or diabetic medications as directed.14 A com-
prehensive review of 50 years of adherence research found a
75.2% mean rate of adherence across a variety of conditions.15
Less-than-optimal medication adherence can result in poor
clinical and health outcomes. In reviewing studies analyzing
adherence and outcomes, “good” adherence had a positive ef-
fect on outcomes in 73% of studies.14 Research examining un-
controlled SBP over time found an odds ratio (OR) of 1.73 for
medication nonadherence related to uncontrolled blood pres-
sure compared with SBP controlled over time.16
Objective
The objective of this study was to evaluate the effect of a
community pharmacy–based hypertension MTM program on
quality of care in patients with both diabetes and hypertension.
Clinical outcomes of care were blood pressure and antihyper-
tensive medication adherence. This study was part of a larger
study of patients with diabetes.
Methods
Study design and setting
A randomized controlled design was used for the study. Us-
ing a generated random number list, participants in a concur-
rent study evaluating a community pharmacy–based diabetes
management program were randomly assigned to either a con-
trol or an intervention group. Participants in the control group
attended visits at baseline and 3, 6, and 9 months, during which
their blood pressure was recorded and they were informed of
blood pressure goals for patients with diabetes. In contrast,
participants in the intervention group received hypertension
MTM services on a monthly basis during the study period.
The hypertension study was nested within a larger study
of patients with diabetes. Participants were screened for the
hypertension study during their baseline visit for the diabetes
study. Patients whose blood pressure was greater than 130/80
www. japh a. or g M a r /A p r 20 0 9 • 4 9 : 2 • JAPhA • 165
 SPECIAL FEATURE Hypertension MTM program in patients with diabetes
mm Hg or who were on antihypertensive therapy were eligible
for the hypertension study. Eligible participants were informed
about the hypertension study and were provided informed con-
sent materials in addition to those for the diabetes study.
Study visits occurred at five pharmacies in Tulsa, OK. These
pharmacies were part of a larger regional pharmacy chain with
approximately 60 stores in the Tulsa area. An administrative
assistant at the regional corporate headquarters was assigned
to contact participants to schedule appointments. Eleven phar-
macists employed by the company were trained by the investi-
gators to provide the study intervention.
The study providers received 3 days of training, which in-
cluded a review and update of current hypertension pharma-
cotherapy and the guidelines described in the Seventh Report
of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure.2 Providers
also were trained on the research protocol, documenting care,
accurate measurement of blood pressure, and strategies for
integrating hypertension MTM services within diabetes man-
agement. To maximize consistent delivery of care, training was
also provided by one of the study investigators during the phar-
macist’s initial patient visit.
Participants
Study participants were members of a managed care orga-
nization (MCO) responsible for more than 100,000 enrollees.
Individuals in this hypertension MTM study were selected from
a larger study of patients with uncontrolled diabetes. Three
recruitment methods were used to enlist individuals from this
MCO into the diabetes study.
The MCO initially screened laboratory data from members
in the greater Tulsa area who had been continuously enrolled
for at least 9 months. If an enrollee’s most recent glycosy-
lated hemoglobin (A1C) level (within the previous 6 months)
was greater than 7.0% (lack of diabetes control, according to
current American Diabetes Association standards of care),17
they were identified as a potential participant for the diabetes
study. This resulted in the MCO mailing recruitment letters to
872 individuals. The letter included a description of the study
and a request to contact the investigators if individuals wished
to participate. Upon contact, the investigators further screened
participants for eligibility. Study participants had to be at least
18 years of age, currently insured by the MCO, not pregnant or
currently enrolled in another diabetes program, and able and
willing to come to periodic visits during a 9-month period.
The second recruitment strategy involved screening at-
tendees at a health fair sponsored by the MCO for City of Tulsa
employees. Point-of-care A1C testing was conducted. Individu-
als with an A1C level greater than 7.0% and meeting the afore-
mentioned eligibility criteria were asked to participate in the
study.
The third recruitment procedure involved the MCO fax-
ing patient referral requests to its network primary care phy-
sicians. Physicians were asked to refer patients whose most
recent A1C level was greater than 7.0% and who agreed to be
contacted by the investigators regarding study participation.
166 • JAPhA • 4 9 : 2 • M a r /A p r 2009 www.j aph a. or g
Participants were screened for the hypertension study at
their baseline diabetes study visit. Participants were eligible
for the hypertension study if their blood pressure was 130/80
mm Hg or higher or they were currently taking antihyperten-
sive therapy. Eligible participants who provided informed con-
sent constituted the hypertension study sample.
Eligible individuals meeting the study criteria were referred
to the patient scheduler, who randomly assigned them to ei-
ther the intervention or the control group based on a previously
generated random number list. The scheduler then identified
the participant’s preferred pharmacy location and scheduled
their baseline visit.
The study was approved by the University of Oklahoma
Health Sciences Center Institutional Review Board.
Intervention
Intervention group participants received hypertension MTM
services on a monthly basis during the same visits in which they
received diabetes management services. During the visits, a de-
tailed history was taken to identify current or potential medical
problems. This history also included a comprehensive assess-
ment of current prescription and nonprescription medications
to identify drug therapy problems. A brief physical examination
was performed, during which the patient’s blood pressure was
recorded. Patients in the intervention group were educated on
diet and lifestyle modifications to lower blood pressure. For
example, patients were encouraged to implement a regular
exercise routine and make dietary changes such as reducing
caloric or sodium intake. During visits, the role of medications
was discussed with the patient and adherence to therapy was
assessed. Patients were encouraged to adhere to their thera-
pies, and an individualized plan was developed for each patient
to help them manage their therapies. Patient visits were doc-
umented, and the patient’s primary care provider was sent a
copy of the visit note. If drug therapy problems were identified,
the pharmacist provider contacted the patient’s primary care
physician via fax or telephone to make recommendations, such
as adjusting medication doses and adding therapeutic agents.
Patients’ progress toward achieving a blood pressure of lower
than 130/80 mm Hg was assessed during their next visit. Previ-
ous recommendations made to the patient’s primary care phy-
sician regarding changes to the hypertensive medication regi-
men were assessed for acknowledgement or implementation
based on facsimile response and/or patient reporting.
Data analysis
Data were entered into a Microsoft Access database and
imported into SPSS version 16.0 (SPSS, Chicago) and SAS ver-
sion 9.1 (SAS Institute, Cary, NC). Descriptive statistics were
reported for study measures. Differences in blood pressure
and antihypertensive medication adherence at baseline and 9
months were compared between the control and intervention
groups.
Two blood pressure measures were evaluated: (1) SBP
levels and (2) percentage of patients at goal blood pressure
(<130/80 mm Hg).2 Intention-to-treat analyses were con-
ducted. If a participant did not complete the study, his or her
Journal of the American Pharmacists Association
 Hypertension MTM program in patients with diabetes SPECIAL FEATURE

last blood pressure level was carried forward to represent the creased 17.32 mm Hg. This difference in SBP change between
9-month level. Participants who dropped out of the study be- the control and intervention groups (20.05 mm Hg [95% CI
fore the 3-month visit were excluded from analyses. 7.45–32.66]) was statistically significant (P = 0.003).
Adherence with medications used in the treatment of hy-
pertension was determined using prescription claims data pro- Goal blood pressure
vided by the MCO. Therefore, all prescription activity was cap- The percentages of participants at goal blood pressure lev-
tured regardless of the pharmacy used by the patient before or els at the baseline and 9-month visits are shown in Figure 2.
during the study period. The date of the participant’s baseline During the study period, the percentage of control group partic-
visit was used to discriminate prescriptions obtained 9 months ipants at blood pressure goal decreased from 20.0% to 6.67%,
before and 9 months after their baseline visit. whereas the percentage of intervention group participants at
Adherence was calculated using the continuous measure goal increased from 16.0% to 48.0%. A statistically significant
of medication acquisition method, in which the days’ supply association was observed between being in the intervention
of a medication is compared with the dates the medication is group and being at goal blood pressure (χ2 = 7.301, P = 0.007).
filled.18 To be included in the analysis, a particular prescription The odds of an intervention group participant achieving goal
medication and dosage (e.g., lisinopril 10 mg) had to be filled at blood pressure were 12.92 times (95% CI 1.47–113.77) great-
least three consecutive times during the 9 months before and/ er than that for a control group participant (P = 0.021).
or after a patient’s baseline visit.
Medication adherence
Independent-samples t tests were used to test group differ-
The mean adherence rate in the control group was 79.5%
ences in mean SBP and medication adherence. A Pearson’s chi-
before the study and 78.8% during the study period. The mean
square test was used to determine if an association existed be-
adherence rate for the intervention group was 80.5% before
tween group assignment and achieving a goal blood pressure.
the study and increased to 87.5% during the study period (Ta-
Additionally, an OR and confidence interval (CI) for achieving
ble 2). Although the mean adherence rate in the intervention
goal blood pressure in the intervention group compared with
group increased 7% while remaining fairly constant in the con-
the control group were calculated. A priori alpha levels of 0.05
trol group, the difference was not statistically significant at the
were used to test for statistical significance.
alpha 0.05 level (P = 0.0712).
Results
Study participation Discussion
A total of 65 participants enrolled in the diabetes study A 9-month community pharmacy–based hypertension
between November 29, 2005, and September 16, 2006. Of
these individuals, 52 met the eligibility criteria for and agreed Table 1. Demographics of patients with diabetes and
to participate in the hypertension study. Twenty participants hypertension participating in study (n = 52)
were randomly assigned to the control group and 32 to the in-
tervention group. The majority of participants were women, Intervention
white, and overweight/obese (Table 1). The 9-month visit for Control group group
the last enrolled patient occurred on July 17, 2007. At the con- n 20 32
clusion of the study, 40 patients were included in the intention- Gender, no. (%)
to-treat analysis (15 control group and 25 intervention group Women 12 (60.0) 21 (65.6)
patients). Men 8 (40.0) 11 (34.4)
The overall drop-out rate was 36.5%, which is slightly Age (years)
higher than that observed in previous pharmacy studies of pa- Mean ± SD 65.2 ± 14.1 64.2 ± 10.5
tients with diabetes.19–25 Drop-out rates were 35.0% and 37.5% Range 34–84 48–82
among control and intervention group participants, respective- Ethnicity, no. (%)
ly. No statistical association was observed between group as- White 18 (90.0) 24 (75.0)
signment and dropping out of the study (χ2 = 0.033, P = 0.855). Black 2 (10.0) 7 (21.9)
Among the 44 participants recruited by letters from the MCO, Hispanic 0 1 (3.1)
34.1% dropped out of the study. None of the four participants Baseline BMIa
who were recruited at a health fair dropped out of the study,
Mean ± SD (kg/m2) 29.7 ± 4.9 32.8 ± 6.9
and all four participants who were recruited by physician refer-
Normal (18.5–24.9 kg/m2), no. (%) 2 (10.5) 5 (15.6)
ral dropped out.
Overweight (25–29.9 kg/m2),
SBP no. (%) 8 (42.1) 5 (15.6)
Mean SBP levels at the baseline and 3-, 6-, and 9-month Obese (≥30 kg/m2), no. (%) 9 (47.4) 22 (68.8)
visits are shown in Figure 1. The mean control group SBP lev- Completed study, no. (%) 13 (65.0) 20 (62.5)
el increased 2.73 mm Hg between the baseline and 9-month Abbreviation used: BMI, body mass index.
a
Missing baseline BMI for one control group participant.
visits. In contrast, the mean intervention group SBP level de-

Journal of the American Pharmacists Association www. japh a. or g M a r /A p r 20 0 9 • 4 9 : 2 • JAPhA • 167

 SPECIAL FEATURE Hypertension MTM program in patients with diabetes

Mean systolic blood pressure 155.00

150.00 148.27 148.13
145.40 144.40
145.00
140.00 Control (n = 15)
141.76
135.00
134.92 Intervention (n = 25)
130.00 132.68
125.00
120.00 124.44
115.00
110.00
0 3 6 9

Month

Figure 1. Mean systolic blood pressure levels at baseline and 3, 6, and 9 months

60.00

50.00 Baseline 48.00

9 Months
40.00

% 30.00

20.00
20.00
16.00

10.00 6.67

0.00
Control (n = 15) Intervention (n = 25)

Group

Figure 2. Participants at goal blood pressure levels at baseline and 9 months

MTM program was evaluated to determine its effect on quality
of care among managed care enrollees with diabetes. Clinical
outcomes among recipients of MTM services were compared
with those of a control group.
The intervention program was effective at improving blood
pressure control. Mean SBP decreased 17.32 mm Hg in the
intervention group, whereas it increased 2.73 mm Hg in the
control group. The percentage of participants at goal blood
pressure increased threefold (from 16.0% to 48.0%) in the
intervention group, whereas it decreased by one-third among
control group participants (from 20.0% to 6.67%). An inter-
vention group participant was 12.92 times more likely than a

168 • JAPhA • 4 9 : 2 • M a r /A p r 2009 www.j aph a. or g Journal of the American Pharmacists Association
 Hypertension MTM program in patients with diabetes SPECIAL
Table 2. Mean adherence rates for antihypertensive medi-
cations 9 months before and after baseline visit
% Mean adherence % Mean adherence
before (95% CI) after (95% CI)
Control groupa 79.5 (71.0–88.1) 78.8 (69.7–87.9)
Intervention groupb 80.5 (74.9–86.0) 87.5 (82.1–93.0)
a
Prescription claims for participants in control group included 29 medications before and 32
medications after baseline visit.
b
Prescription claims for participants in intervention group included 55 medications before and 61
medications after baseline visit.
control group participant to achieve a goal blood pressure of
less than 130/80 mm Hg (P = 0.021).
The United Kingdom Prospective Diabetes Study (UKPDS)
demonstrated that lowering blood pressure significantly re-
duced the risks of diabetes-related complications.8 However,
NHANES data from 2004 suggested that only 48% of patients
with diabetes have a blood pressure controlled to the recom-
mended goal of less than 130/80 mm Hg.6 Additionally, among
treated hypertensive patients with diabetes, only 37.5% are at
the recommended goal blood pressure. The current study had a
small number of participants; however, the reduction in blood
pressure for the intervention group patients was clinically sig-
nificant. In the UKPDS, a 10–mm Hg decrease in blood pres-
sure reduced the risk of cardiovascular morbidity and mortality
from stroke and myocardial infarction in patients with diabetes
and reduced the risk of developing microvascular complica-
tions. Other large randomized controlled hypertension trials
that included high numbers of patients with diabetes support
the findings that improvements in blood pressure can improve
outcomes in the diabetic population.26–28
Medication management involves many facets of behav-
ioral change, one of which is taking medications on a regular
basis. Improvements in antihypertensive medication adher-
ence were seen in the intervention group, but these changes
were not statistically significant because of sample size of the
study. The calculated post hoc power for the study was only
18%. Thus, the small sample size was inadequate to provide
sufficient power to detect the moderate effect size (d) seen in
the intervention group (d = 0.33).
Limitations
This study has several limitations that should be consid-
ered. First, despite multiple recruitment strategies, the number
of study participants was smaller than planned, thus limiting
the sample size and power. The recruitment methods and drop-
out rates were factors in the resulting sample size. One way to
increase participation in future studies is to recruit more pa-
tients in person, such as at care settings or employer sites. The
drop-out rates in this study seemed to have been influenced
by the recruitment method, with the more personal approach
yielding more participants who completed the study. This ap-
proach generally requires more time, however, so the feasibil-
ity of each type of recruitment method should be weighed in
future studies.
The study results have limited generalizability to all man-
Journal of the American Pharmacists Association
FEATURE
aged care enrollees with hypertension and diabetes because
of potential selection bias among program participants. These
individuals may have been more highly motivated than the av-
erage patient.
Conclusion
A community pharmacy–based hypertension MTM program
was effective in improving blood pressure control among man-
aged care enrollees with diabetes and hypertension. Commu-
nity pharmacists are strategically positioned to provide MTM
services and effectively communicate with providers to help
maximize patient outcomes and improve quality of care.
References
1. Ong KL, Cheung BMY, Man YB et al. Prevalence, awareness,
treatment, and control of hypertension among United States
adults 1999-2004. Hypertension. 2007;49:69–75.
2. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the
Joint National Committee on Prevention, Detection, Evalua-
tion, and Treatment of High Blood Pressure. Hypertension.
2003;42:1206–52.
3. Parving HH. Controlling hypertension in diabetes. Acta Diabetol.
2002;39(suppl 2):S35–40.
4. Centers for Disease Control and Prevention. National diabetes
fact sheet: general information and national estimates on dia-
betes in the United States, 2007. Atlanta, GA: U.S. Department
of Health and Human Services, Centers for Disease Control and
Prevention; 2008.
5. American Diabetes Association. Standards of medical care in
diabetes–2008. Diabetes Care. 2008;31(suppl 1):S12–54.
6. Ong KL, Cheung BMY, Wong LYF, et al. Prevalence, treatment,
and control of diagnosed diabetes in the U.S. National Health
and Nutrition Examination Survey 1999-2004. Ann Epidemiol.
2008;18:222–9.
7. Stratton IM, Adler AI, Neil HAW, et al. Association of glycaemia
with macrovascular and microvascular complications of type
2 diabetes (UKPDS 35): prospective observational study. BMJ.
2000;321:405–12.
8. Adler AI, Stratton IM, Neil HAW, et al. Association of systolic
blood pressure with macrovascular and microvascular compli-
cations of type 2 diabetes (UKPDS 36): prospective observational
study. BMJ. 2000;321:412–9.
9. Park JJ, Kelly P, Carter BL, Burgess PP. Comprehensive phar-
maceutical care in the chain setting. J Am Pharm Assoc.
1996;NS36:443–51.
10. Carter BL, Barnette DJ, Chrischilles E, et al. Evaluation of hyper-
tensive patients after care provided by community pharmacists
in a rural setting. Pharmacotherapy. 1997;17:1274–85.
11. Erickson SR, Slaughter R, Halapy H. Pharmacists’ ability to in-
fluence outcomes of hypertension therapy. Pharmacotherapy.
1997;17:140–7.
12. Chabot I, Moisan J, Gregoire JP, Milot A. Pharmacist interven-
tion program for control of hypertension. Ann Pharmacother.
2003;37:1186–93.
13. Bunting BA, Smith BH, Sutherland SE. The Asheville Project: clin-
ical and economic outcomes of a community-based long-term
medication therapy management program for hypertension and
www. japh a. or g M a r /A p r 20 0 9 • 4 9 : 2 • JAPhA • 169
 SPECIAL FEATURE HyPERTENSiON MTM PROGRAM iN PATiENTS wiTH DiABETES

dyslipidemia. J Am Pharm Assoc. 2008;48:23–31.
14. Cramer JA, Benedict A, Muszbek N, et al. The significance of com-
pliance and persistence in the treatment of diabetes, hypertension
and dyslipidaemia: a review. int J Clin Pract. 2008;62:76–87.
15. DiMatteo MR. Variations in patients’ adherence to medical rec-
ommendations: a quantitative review of 50 years of research.
Med Care. 2004;42:200–9.
16. Ho PM, Magid DJ, Shetterly SM, et al. importance of therapy
intensification and medication nonadherence for blood pres-
sure control in patients with coronary disease. Arch intern Med.
2008;168:271–6.
17. American Diabetes Association. Clinical practice recommenda-
tions 2005. Diabetes Care. 2005;28(suppl 1):S1–79.
22. Nau DP, Ponte CD. Effects of a community pharmacist-based
diabetes patient-management program on intermediate clinical
outcome measures. J Manag Care Pharm. 2002;8:48–53.
23. Cranor Cw, Christensen DB. The Asheville Project: short-term
outcomes of a community pharmacy diabetes care program. J
Am Pharm Assoc. 2003;43:149–59.
24. Cranor Cw, Bunting BA, Christensen DB. The Asheville Project:
long-term clinical and economic outcomes of a community phar-
macy diabetes care program. J Am Pharm Assoc. 2003;43:173–84.
25. irons BK, Lenz RJ, Anderson SL, et al. A retrospective cohort
analysis of the clinical effectiveness of a physician-pharmacist
collaborative drug therapy management diabetes clinic. Phar-
macotherapy. 2002;22:1294–300.

18. Steiner JF, Prochazka AV. The assessment of refill compliance
using pharmacy records: methods, validity, and applications. J
Clin Epidemiol. 1997;50:105–16.
19. Coast-Senior EA, Kroner BA, Kelley CL, Trilli LE. Management of
patients with type 2 diabetes by pharmacists in primary care clin-
ics. Ann Pharmacother. 1998;32:636–41.
20. Gerber RA, Liu G, McCombs JS. impact of pharmacist consulta-
tions provided to patients with diabetes on healthcare costs in a
health maintenance organization. Am J Manag Care. 1998;4:991–
1000.
21. Berringer R, Shibley MC, Cary CC, et al. Outcomes of a communi-
ty pharmacy-based diabetes monitoring program. J Am Pharm
Assoc. 1999;39:791–7.
26. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive
blood-pressure lowering and low-dose aspirin in patients with
hypertension: principal results of the Hypertension Optimal
Treatment (HOT) randomised trial. Lancet. 1998;351:1755–62.
27. yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-con-
verting-enzyme inhibitor, ramipril, on cardiovascular events in
high-risk patients. N Engl J Med. 2000;342:145–53.
28. ALLHAT Officers and Coordinators for the ALLHAT Collabora-
tive Research Group. Major outcomes in high-risk hypertensive
patients randomized to angiotensin-converting enzyme inhibitor
or calcium channel blocker vs diuretic: the Antihypertensive and
Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALL-
HAT). JAMA. 2002;288:2981–97.

The script for success.

A healthy career awaits.
As one of our pharmacists, you’re on the frontline of personal
healthcare, providing valuable service, award-winning clinical
care programs and counsel to a wide variety of patients. With
more than 2,400 stores in 31 states, opportunities exist to
accommodate virtually every lifestyle.
Expectations fulfilled here.
In addition to staff and management positions, 12 residency
programs are also available. To inquire about a position at any
level, please visit www.kroger.com or e-mail
krogerresumes@kroger.com.
Stop by our APhA Booth #1637 for your invitation to our private
breakfast on Sunday, April 5th at Rivercenter.

The Kroger Family of Pharmacies

®

17009KGO196_pharmAd-1.indd
• JAPhA • 4 9 : 2 • M a r /a
1 p r 2009 www.j aph a. or g J o u r n a l o f t h e A m e r i c a n P h a r m a c1/29/09
i s t s A s2:27:45
s o c i a tPM
ion