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Optimizing Pharmacotherapy in Pulmonary Arterial Hypertension with a Specialty Pharmacy Clinical Care Management Program

Lesley D'Albini

Douglas Mager

Mary Dorholt

Jean Bergwall


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Conference: 2017 PH Professional Network Symposium

Release Date: 10.06.2017

Presentation Type: Abstracts

File Download: 2017 PHPN Abstract 1022

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Abstract presented at the 2017 PH Professional Network Symposium held in Bethesda, MD on October 5-7, 2017


The application of a Clinical Care Management program at the specialty pharmacy (SP) level can prolong positive outcomes of oral therapy and alert prescribers to potential clinical worsening which may necessitate advancement through the evidence-based treatment algorithm. 


Pulmonary arterial hypertension (PAH) is a rapidly progressive disease; early detection and management of clinical worsening is paramount to optimizing long-term outcomes.


Claims data was retrospectively reviewed to evaluate the impact of the SP clinical model. Patients were included if they: carried a diagnosis of PAH, were newly diagnosed (no prior claims for a PAH medication), had a prescription for an endothelin receptor antagonist (ETRA) or a phosphodiesterase type 5 (PDE-5) inhibitor and were continuously eligible with uninterrupted admission to the SP through the review period. Patients were divided into groups by pharmacotherapy: ETRA or PDE-5 inhibitor. Patients in the ETRA group were evaluated via the Clinical Assessment and Risk Evaluation (CARE) protocol; monthly screening for potential clinical worsening during routine reorder placement. On identification of a potential clinical worsening event, the patient was triaged to a PAH specialist nurse for assessment. As opportunities were identified, intervention strategies to optimize therapy were offered and the prescriber engaged as warranted.

The primary endpoint was the rate of and time to prostanoid combination therapy: the secondary endpoint was adherence to the index therapy. An exploratory endpoint included review of interventions offered by the specialist nurse.


6551 patients met the inclusion criteria; 3506 on an ETRA and assessed per the CARE protocol (intervention group) and 3045 on a PDE-5 inhibitor (control). The rate of progression to prostanoid combination therapy was significantly higher in the intervention group (9.4% vs. 7.0%; p=0.0043). The average time to prostanoid combination therapy also differed between the two groups, with a trend toward a longer duration of oral monotherapy in patients on the ETRA and assessed per CARE (140.2 days intervention group vs. 112.7 days’ control).

Adherence to pharmacotherapy, as measured by average adjusted prescriptions, was significantly higher in the intervention group referred to a PAH specialist nurse for potential clinical worsening (14 vs. 13.5; p=0.0004).

166 (4.7%) patients in the intervention group were identified as having a potential clinical worsening event on routine monthly reorder triggering assessment by a PAH specialist nurse. 207 interventions were performed to address root cause of clinical worsening. See Figure 1 for intervention by type: 


Our data show that the application of an evidence-based protocol to detect potential clinical worsening will drive appropriate escalation to prostanoid combination therapy while management of the root cause may delay the time to that progression – an average of 27.5 days in this sample. The Clinical Care Management program also significantly increases adherence to pharmacotherapy.