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. 2025 Apr 22;18:100607. doi: 10.1016/j.rcsop.2025.100607

Enhancing holistic patient care of black individuals diagnosed with HIV and comorbid chronic conditions

Marc Fleming a,⁎,1, Saharnaz Nedjat b, Jon C Schommer c, Crystal K Hodge d,e
PMCID: PMC12433802  PMID: 40959231

Abstract

Background

Pharmacists can play a crucial role in delivering the holistic care model. Research suggests that HIV-positive African American patients particularly benefit from this approach compared to other communities. Typically, pharmacists in community pharmacy settings are limited in their access to a patient's medical record, preventing holistic care delivery.

Objectives

This study addressed the impact of access to medical records on a holistic patient care approach among pharmacists engaged in medication therapy management.

Methods

This was a sub-analysis of a randomized controlled trial of the impact of community pharmacist access to medical records during MTM for African Americans diagnosed with HIV and multimorbidity with hypertension (HTN) and/or type 2 diabetes mellitus (DM). A random sample was selected of 30 participants (15 in the intervention arm with access to medical records and 15 in the control arm) who completed at least seven study visits between 2019 and 2021. A quantitative content analysis of the study pharmacist visit notes was conducted to identify themes of pharmacist interventions. The percentages of the theme's repetitions were compared across study groups using the Fisher exact test.

Results

Thirteen themes were extracted from the pharmacists' visit notes. The intervention group demonstrated a higher repetition of themes concerning any disease, medicine, exercise/weight/diet, sexual, sleeping, smoking, alcohol/marijuana, vaccination, will/power of attorney, food/ housing, and depression/stress. Themes related to career goals and recommending consultation with a provider were repeated more in the control group. The two study groups had statistically significant differences in the percentages of repetition of seven themes.

Conclusion

Access to medical records enables pharmacists to focus more on mental health, lifestyle, and social determinants of health.

Keywords: AIDS, Holistic patient care, Comorbidity, Diabetes, Hypertension, Pharmacists

1. Introduction

Multimorbidity, the coexistence of multiple long-term conditions in one individual, presents a complex challenge in healthcare and a priority in global health research.1 Managing chronic diseases and multimorbidity is intricate, leading to increased safety risks, such as polypharmacy, complex medication interactions, and lack of care coordination resulting from the involvement of multiple healthcare professionals.2 Advocates propose patient-centered comprehensive treatment programs, addressing various life domains, aiming to meet specific individual needs and enhance overall satisfaction with care.

As antiretroviral therapy (ART) becomes more widely accessible, individuals with human immunodeficiency viruses (HIV) in the United States are living longer, exposing them to the risk of chronic diseases.3 Moreover, ART can cause the development of adverse events leading to decreased adherence, potentially resulting in ART resistance.4 HIV is also correlated with an elevated risk for cardiovascular disease (CVD).5 According to the literature, hypertension (HTN) and diabetes mellitus (DM) are more prevalent among non-Hispanic Blacks compared to non-Hispanic Whites.6 Expanding clinical care is vital for the successful management of the complexities stemming from multiple potentially interacting diseases in persons with HIV (PWH). As with the general population, effectively preventing HTN and DM among PWH may necessitate addressing underlying social factors.7,8 It was shown that pharmacists' insights into therapy issues, such as treatment adherence, can enhance the overall quality of patient care among PWH.9

Pharmacists, at the heart of medication provision and primary health care (PHC), are pivotal in managing drug interactions and contributing to patients' holistic healthcare teams.10 Holistic care is characterized by acknowledging an individual as a complete entity and recognizing the interconnectedness of their physical, mental, social, and spiritual dimensions.11

Patients generally express satisfaction with their communication with pharmacists, considering them a reliable source of medication information.12 Additionally, community pharmacists showed a positive attitude toward using clinical decision-support tools, enabling them to identify and refer patients with serious diseases earlier.13 According to a systematic review, patient questions, responses, expectations, demands, and belief systems significantly impact patient-pharmacist interpersonal communication.14

As one of the most accessible healthcare professions, it is unsurprising that evidence supports the importance of pharmacist interventions in the community. It was shown that DM screening services led by pharmacists provided an exceptional opportunity for screening and referral for Aboriginal/Torres Strait Islander peoples.15 According to a mixed methods study, knowledge exchange between patients with asthma and pulmonary HTN and pharmacists could improve the self-care skills of patients.16 Furthermore, a qualitative study on African American women and health care providers, including pharmacists, indicated that patient-centered and holistic care, adequacy of patient counseling, and education improved treatment adherence among HIV patients.17

In a clinical trial with 411 patients with diabetes, pharmacist-involved collaborative care positively impacted patients' clinical outcomes (e.g., HbA1c), treatment satisfaction rate, and diabetes-related health service costs.18 Moreover, a community pharmacy counseling program addressing lifestyle, medication adherence, and medication management for cardiovascular disease prevention demonstrated satisfactory cardiovascular health outcomes.19

Medication therapy management (MTM) is a specialized service that optimizes patients' therapeutic outcomes. It involves many professional activities, including verbal education, necessary health assessments, and training to enhance patient understanding. MTM also focuses on assessing and monitoring the patient's response to therapy, addressing safety and effectiveness concerns, and resolving or preventing medication-related problems.20 According to the literature, MTM consistently improved clinical outcomes among people with DM, HTN, and PWH.21, 22, 23, 24 In accordance with the literature, collaboration between pharmacists engaged in medical records-based MTM and medical care providers can improve viral suppression and HIV care retention across different demographic groups living with HIV, particularly in black patients.24,25

No prior studies have been identified that directly assessed the impact of MTM or access to patients' medical records on holistic patient care. This gap might be due to the considerable heterogeneity in implementing MTM.26,27 Importantly, community pharmacies are not provided with access to a patient's medical record in the usual course of care.28

This study is a sub-analysis of primary research addressing whether pharmacist access to medical records improves patient clinical outcomes in African American PWH and either HTN, DM, or both. The current study aims to evaluate pharmacist notes qualitatively and quantitatively from the primary study's MTM sessions to address the impact of access to medical records on holistic care. This enables an evaluation of the impact of sharing medical records with pharmacists within one marginalized community, where the holistic patient care approach may offer more benefits than other communities.24,25 It is also the first study to address this question using quantitative content analysis.

2. Methods

2.1. Parent trial

This was a sub-analysis of a prospective, randomized, clinical trial (NCT03437694) conducted in the Dallas-Fort Worth metroplex between 2018 and 2023 that compared the impact of pharmacist access to medical records on clinical outcomes in Black PWH. Participant eligibility criteria included African American self-identification, age 18 years or older, HIV diagnosis, and multimorbidity of HTN, DM, or both. The initial target sample size for the trial was 200 study participants to allow for randomization blocks by study arm and self-identified gender and provide a power of 80 %, assuming an effect size of 45 % in the control group. Due to recruitment challenges secondary to the pandemic, the target sample size was later decreased to 100 participants. Recruitment included study advertisements to HIV providers and clinics in the metroplex, bus advertisements, flyers, and a study recruitment website. Study participants received financial reimbursement upon completion of each study visit. At the initial screening visit, informed consent and medical records release forms were obtained in accordance with approval from the North Texas Regional IRB.

After study enrollment, participants were randomized 1:1 to the control or intervention arm (pharmacist access to medical records) to complete eight MTM visits with a community pharmacist at a large chain specialty pharmacy in the DFW area approximately every 90 days. Study visits for participants in the control arm included standard of care medical records access for the study pharmacists, which was limited to medication records if the study participant used that pharmacy (not a requirement for study participation) and any additional information the study participant could recall and provide during their study visit. Medical records were periodically requested by the study coordinator for participants in the control arm for data analysis but were not provided to the study pharmacist conducting the study visit. Medical records were requested from the participant's designated provider prior to each study visit for study participants in the intervention arm. The study coordinator then prepared a summary (i.e., a surrogate for routine medical records access) for the study pharmacist, including disease diagnosis and progress, pertinent HIV or multimorbidity labs (e.g., hemoglobin A1c, HIV viral load), medications, and medical history. During the MTM study visit, regardless of study arm, study participants participated in an IRB-approved questionnaire that assessed social determinants of health factors, and visit notes were prepared by the study coordinator and study pharmacist. Visit documentation was only for study purposes and was not shared with the participant's provider. This was to simulate standard practice in the State of Texas, where community pharmacists rarely have access to patient medical records systems and, if they do, are largely limited to view-only access.

2.2. Sub-analysis

This study was a secondary exploratory analysis employing the primary study data to provide a quantitative thematic content analysis of pharmacist notes from clinical trial study visits. A random sample of 30 study participants (15 per study arm) with a minimum of seven visits between 2019 and 2021 was selected for the quantitative content analysis. A quantitative content analysis entails extracting and counting codes and categories and comparing them using statistical tests.29 Dedoose® software, a qualitative and mixed methods data analysis application, assisted with data management and analysis.30 Pharmacists' visit notes were uploaded into Dedoose® along with the participant's demographic information and whether the participant was in the control or intervention group. The research team used an iterative process in reviewing pharmacist study visit notes to explore patterns and conduct staged coding to develop the final codebook. The initial open coding utilized a deductive approach derived from the intake questionnaire and the structure of the pharmacists' study visit notes. Deductive codes included pharmacists' recommendations (e.g., disease state, medication discussion), preventive and routine healthcare (e.g., vaccinations, diet, and exercise), pharmaceutical care (e.g., medication adherence), and HIV status. Subsequent coding used an inductive approach based on the pharmacist's notes and patient perspectives (stress, depression, social context, and relationships).

To assess the themes quantitatively, repeated mentions were totaled between the intervention group and the control group to assess the consistency of discussions across the two study arms (Table 2) as a proxy for pharmacist-patient engagement. The Fisher exact test was applied to check for statistical differences in the percentages of theme repetitions (number of each theme repetitions/sum of themes' repetitions in each group) across the two study arms, using STATA 17 (STATA Corp, College Station, TX).

Table 2.

Comparison of theme repetitions across intervention and control groups.

Themes Number of themes (% of the sum of the themes repetitions in each study arm)
 Significance level
Fisher exact test		 Total number of themes repetitions (n = 30)
Intervention (n = 15) Control (n = 15)
Vaccination 290 (19.9⁎) 214 (27.9) P < 0.001 504 (22.6⁎)
Exercise/Weight/Diet 349 (23.9) 128 (16.7) P < 0.001 477 (21.2)
Disease State (HTN⁎⁎/Diabetes/HIV) 232 (15.9) 138 (18.0) 0.209 370 (16.6)
Will/POA⁎⁎⁎ 152 (10.4) 93 (12.1) 0.226 245 (11)
Medicine-based⁎⁎⁎⁎ 103 (7.1) 70 (9.1) 0.096 173 (7.8)
Food and Housing 124 (8.5) 9 (1.2) P < 0.001 133 (6)
Recommending consultation with a provider 44 (3.0) 80 (10.4) P < 0.001 124 (5.6)
Smoking and Tobacco 82 (5.6) 23 (3.0) 0.006 105 (4.7)
Depression and Stress 36 (2.5) 11(1.4) 0.122 47 (2.1)
Sleeping 25 (1.7) 0 (0) P < 0.001 25 (1.1)
Alcohol and Marijuana 19 (1.3) 4 (0.5) 0.121 23 (1)
Sexual 4 (0.3) 3 (0.4) 0.697 7 (0.3)
Career Goals 0 (0) 3 (0.4) 0.040 3 (0.1)
Sum of the 13 Repeated Themes 1460 (100) 768 (100) 2228
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Bold indicates significant differences.

⁎

290/1460 = 19.9 % and 504/2228 = 22.6 %.

⁎⁎

Hypertension.

⁎⁎⁎

Power of attorney.

⁎⁎⁎⁎

Adherence, side effects, missing dose.

3. Results

Table 1 shows the gender and multimorbidity distributions among study participants in the two study arms. The percentage of males within the control group was over twice that in the intervention group (73.3 % vs. 33.3 %). The prevalence of having both HTN and type 2 DM (66.7 %) in the control group was twice as high as in the intervention group. Thirty-two codes were extracted from visit notes and finally integrated into 13 themes across both study arms. When considering all patients in the two study arms, more than 75 % of the repeated themes were related to the patients' lifestyles, mental health, and social determinants of health (SDOH) (last column (Table 2). All repeated themes were higher in the intervention group, except for career goals and recommending consultation with a provider, which were repeated more in the control group. The sum of the 13 repeated themes in the intervention group was 1460 compared to 768 in the control group. When comparing percentages of repeated themes (number of each repeated theme/sum of repeated theme in each group) across study groups, the intervention group showed 7.2 % higher percentage of repetition in exercise/weight/diet (P < 0.001), 1.7 % higher percentage in sleeping (P < 0.001), 2.6 % higher percentage in smoking and tobacco (P = 0.006) and 7.3 % higher percentage in food and housing (P < 0.001) than the control study group.

Table 1.

Distribution of study participants by gender and multimorbidity across intervention and control groups.

Groups Intervention group N = 15 Control group N = 15
Gender
Male 5 (33.3 %) 11 (73.3 %)
Female 10 (66.7 %) 4 (6.7 %)
Comorbidity
HTN⁎ & Diabetes 5 (33.3 %) 10 (66.7 %)
HTN 10 (66.7 %) 5 (33.3 %)
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⁎

Hypertension.

Although the number of vaccination-related theme repetitions in the intervention group was 290 compared to 214 in the control group, the control group had an 8 % higher percentage of vaccination-related theme repetition than the intervention group (P < 0.001). However, the number and percentages of theme repetitions in career goals and recommending consultation with a provider were both higher in the control group (P = 0.04 and P < 0.001, respectively). Recommending consultation with a provider encompassed patients consult with a provider (e.g., physician, psychiatrist, or therapist). While the repetition numbers of disease state (n = 232 [15.9 %]), medicine-based (n = 103 [7.1 %]), and will/power of attorney (POA) themes (n = 152 [10.4 %]) were higher in the intervention group, their percentages of repetitions were lower in the intervention group than in the control group. However, these differences were not statistically significant.

4. Discussion

Based on the findings from this study, pharmacists with access to a patient's medical records (i.e., intervention group) discussed the following health topics more consistently concerning any disease state, medication, exercise/weight/diet, sexual (e.g., partner protection), sleeping, smoking and tobacco, alcohol, and Marijuana, vaccination, will/POA, food, and housing, depression and stress when compared to patients in the control group, as expected. The sum of the theme repetitions within the intervention group was nearly twice as high as that observed in the control group. However, career goals and provider consultations were repeated more in the control group. Additionally, considering the sum of the repeated themes across both study arms, only 24.4 % were directly related to patients' disease states and medicines. This finding underscores pharmacists' engagement with SDOH while delivering MTM. Pharmacists with access to patients' medical records had significantly higher percentages of repeated themes pertaining to lifestyle and SDOH than those in the control group. These findings demonstrate that access to patients' medical records can enhance pharmacists' capacity to deliver holistic patient care.

According to the literature, social, economic, political, and environmental factors significantly impact patient outcomes, often more than just medical care.31,32 All healthcare providers, including community pharmacists, should consider these factors. Access to patients' medical records empower pharmacists to make more precise and patient-centered decisions, reducing variations influenced by individual pharmacists' knowledge and experience. Moreover, providing medical records to community pharmacists engaged in MTM improves patients care by resolving inconsistencies in the patient's medical history.33

A study showed that expanding clinical roles for pharmacists through their access to medical records improved Indian patient care.34 Additionally, two systematic reviews demonstrated the influential roles of community pharmacies in various public health interventions such as smoking cessation, weight management, health promotion, disease screening, and preventive activities, including cardiovascular diseases, vaccination, alcohol dependence advice, and drug misuse, hormonal contraception, and sexual health services.35,36 Correspondingly, the study findings reported here indicate pharmacists with access to patient medical records could enhance holistic care of PWH and HTN, DM, or both.

As shown in Table 2, while the themes' repetitions were higher in the intervention arm, the percentage of them was higher in the control arm. The prevalence of having both HTN and DM multimorbidity was higher in the control group (Table 1). It could lead to more patients being recommended to consult with a physician or an external person. This circumstance might contribute to higher percentages of disease state and medicine-based themes’' repetitions within the control group (18 % and 9.1 % in the control group compared to 15.9 % and 7.1 % in the intervention group). However, the differences were not statistically significant (P = 0.209 and P = 0.096). It is also possible that this non-statistically significant difference could be influenced by the pharmacist's improved assessment abilities when the pharmacist could review medical records.

Nonetheless, access to medical records might reduce pharmacists' need to focus predominantly on asking questions or making recommendations about disease and medicine. For example, when the pharmacist has access to a patient's A1c, they can determine if they are controlled and if they need further intervention. If they don't have access to an A1c, they may just routinely recommend consulting their physician for adjustment to diabetes medications. Accessing patients' records might also give them additional time to address holistic and individualized patient issues as well as medicine-based recommendations.

However, the higher percentage of women in the intervention group should be considered when interpreting the findings. Existing literature indicates that women seek consultations more frequently than men, and this difference remains significant even after controlling for health status and other potential confounders.37, 38, 39 The women have lower self-rated health, quality of life scores, and health satisfaction, which leads to more questions and seeking more services from their healthcare providers.40, 41, 42 Accordingly, 1460 repeated themes were observed in the intervention group, compared to 768 in the control group, with a portion being to the gender imbalance across study groups.

According to the literature, vaccine literacy levels vary by gender.43, 44, 45 Therefore, the higher percentage of vaccination-related theme repetition in the control group could be partially attributed to the higher number of men in this group. In other words, men might require additional information about the benefits and harms of vaccinations. Moreover, access to medical records enabled community pharmacists to be well-informed about the vaccination details in the intervention group, reducing the necessity for additional questions or recommendations within this group.

The frequency and percentages of repetition of depression or stress themes were higher in the intervention group. However, women are more stigmatized and marginalized by HIV/AIDS46; hence, a higher percentage of women in the intervention group might also increase the repetition and percentage of depression or stress themes in this group.

According to a study on PWH in 2006, the odds of employment were lower among women than men.47 Therefore, the higher repetition of career goals in the control group can be attributed to the higher percentage of men in this group.

SDOH are considered very influential contextual factors on patient health outcomes. Pharmacy education typically emphasizes the clinical aspects of patients, while in real-world practice, they are required to view both clinical and SDOH, enabling them to provide holistic patient care. As the literature shows, there are endeavors to employ patient cases encompassing both aspects in the core pharmacy curriculum, integrating clinical and social factors into their treatment approach.32

Increasing holistic patient care among community pharmacists requires education and strategic planning. Access to patients' medical records can be considered a potentially cost-effective approach to enhancing it. Nevertheless, conducting a randomized controlled trial with a larger and more diverse sample size is advisable for a more robust and accurate assessment of this intervention.

5. Study limitations and strengths

The study has several limitations to consider, such as a small sample size. Moreover, the study was only conducted with participants from the DFW area. Thus, generalizability to others outside of this geographic area is not feasible. Further, caution should be warranted due to the unbalanced distribution of confounders such as gender and multimorbidity across study groups. Given the nature of the intervention, blinding was not possible. Notably, the pharmacists were unaware of this study's assumption, as holistic patient care was not the focus of the primary research. Consequently, the likelihood of information bias was minimal.

The community pharmacists visiting the patients were the same; hence, the observed differences cannot be attributed to variations in pharmacists' knowledge, attitude, or practice. Additionally, the flexible and exploratory nature of quantitative content analysis allowed for testing novel aspects of health services approaches.

6. Conclusion

This study represents a preliminary endeavor to explore the influence of medical record access on patient holistic care delivered by community pharmacists. Access to the patient's medical records improved holistic patient care among community pharmacists. It allowed pharmacists to dedicate more time to addressing contextual aspects of a patient's life, significantly impacting their overall quality of life and other health outcomes.

CRediT authorship contribution statement

Marc Fleming: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Conceptualization. Saharnaz Nedjat: Writing – original draft, Formal analysis. Jon C. Schommer: Writing – review & editing, Conceptualization. Crystal K. Hodge: Writing – review & editing, Supervision, Project administration, Investigation.

Ethical approval

The study was approved by the North Texas Regional Institutional Review Board (NTRIRB approval #2018–094).

Disclaimer

The funding source was not involved in the study design, collection, analysis, interpretation of data, the writing of the report, nor the decision to submit the article for publication.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

The authors would like to acknowledge a PhD student, Poonam Bhatjire, who supported the editing of the manuscript. This study was funded by the National Institutes of Health (5U54MD006882-08)

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