The impact of pharmacist/physician care on quality of life in elderly heart failure patients: results of the PHARM-CHF randomized controlled trial

Low Natriuretic Peptide Levels and Outcomes in Patients With Heart Failure and Preserved Ejection Fraction

BACKGROUND

Although some patients with heart failure (HF) with mildly reduced/preserved ejection fraction have low natriuretic peptide levels, there are no large-scale systematic studies of how common these individuals are or what happens to them.

OBJECTIVES

The purpose of this study was to examine the proportion of patients in the I-PRESERVE (Irbesartan in Heart Failure with Preserved Ejection Fraction) trial with an N-terminal pro-B-type natriuretic peptide (NT-proBNP) level <125 pg/mL, their clinical characteristics, and outcomes.

METHODS

I- PRESERVE enrolled patients with symptomatic HF and a LVEF ≥45% but who did not have NT-proBNP or body mass index inclusion/exclusion criteria. Baseline NT-proBNP was measured after enrollment but not reported to investigators. The primary outcome in this analysis was the composite of cardiovascular death or HF hospitalization.

RESULTS

Overall, 808 of 3,480 patients (23.2%) had NT-proBNP <125 pg/mL. Patients with a low NT-proBNP were younger (68.6 years vs 72.6 years; P < 0.001), were less often men (36.1% vs 40.9%; P = 0.015), and had a higher body mass index (48.4% vs 38.7% obese; P < 0.001) than those with a higher NT-proBNP level. Patients with a low NT-proBNP had less atrial fibrillation (8.5% vs 35.1%; P < 0.001), myocardial infarction, diabetes, chronic obstructive pulmonary disease, and anemia but better kidney function. Patients with a lower NT-proBNP level had less marked echocardiographic abnormalities and were less likely to experience cardiovascular death or HF hospitalization; adjusted HR: 0.35 (95% CI: 0.27-0.46; P < 0.001). However, health status was similarly impaired in patients with lower and higher NT-proBNP levels (median Minnesota Living with Heart Failure Questionnaire 43 vs 43; P = 0.95).

CONCLUSIONS

Almost one-quarter of patients with HF with mildly reduced/preserved ejection fraction had a low NT-proBNP level. Although these patients have a favorable prognosis, compared to those with a high NT-proBNP level, they have similarly impaired health status which should be a target for treatment. (Irbesartan in Heart Failure With Preserved Systolic Function [I- PRESERVE]; NCT00095238).

Components of pharmacist-led medication reviews and their relationship to outcomes: a systematic review and narrative synthesis

INTRODUCTION

Pharmacist-led medication reviews are an established intervention to support patients prescribed multiple medicines or with complex medication regimes. For this systematic review, a medication review was defined as 'a consultation between a pharmacist and a patient to review the patient's total medicines use with a view to improve patient health outcomes and minimise medicines-related problems'. It is not known how varying approaches to medication reviews lead to different outcomes.

AIM

To explore the common themes associated with positive outcomes from pharmacist-led medication reviews.

METHOD

Randomised controlled trials of pharmacist-led medication reviews in adults aged 18 years and over were included. The search terms used in MEDLINE, EMBASE and Web of Science databases were "medication review", "pharmacist", "randomised controlled trial" and their synonyms, time filter 2015 to September 2023. Studies published before 2015 were identified from a previous systematic review. Risk of bias was assessed using the Cochrane risk of bias 2 tool. Descriptions of medication reviews' components, implementation and outcomes were narratively synthesised to draw out common themes. Results are presented in tables.

RESULTS

Sixty-eight papers describing 50 studies met the inclusion criteria. Common themes that emerged from synthesis include collaborative working which may help reduce medicines-related problems and the number of medicines prescribed; patient involvement in goal setting and action planning which may improve patients' ability to take medicines as prescribed and help them achieve their treatment goals; additional support and follow-up, which may lead to improved blood pressure, diabetes control, quality of life and a reduction of medicines-related problems.

CONCLUSION

This systematic review identified common themes and components, for example, goal setting, action planning, additional support and follow-up, that may influence outcomes of pharmacist-led medication reviews. Researchers, health professionals and commissioners could use these for a comprehensive evaluation of medication review implementation.

PROSPERO REGISTRATION NUMBER

CRD42020173907.

Patient-pharmacist relationship dynamics: a mediation analysis of patient characteristics and reported outcomes

Background

While previous research underscores the independent effect of the pharmacist-patient relationship on patient outcomes, it did not delve further into the patient-pharmacist relationship dynamics and their effects on reported outcomes. Therefore, this study aimed to assess whether patient-pharmacist relationship aspects mediate the association between patient personal and health characteristics, on the one hand, and adherence to medication and quality of life, on the other hand (QOL).

Methods

An online cross-sectional study was conducted between April 11 and 27, 2023. It enrolled 865 adults from all Lebanese governorates and used validated scales to measure the various concepts.

Results

The mean age was 32.52 ± 14.56 years, and 68.8% were female. Also, 79.3% reported having no chronic disease, and 57.7% indicated that getting nonprescription medications was the main reason for visiting a community pharmacy. The average routine intake of medications per day was 0.87 ± 1.78. Our key findings reveal a compelling association between worse health status and both increased medication non-adherence and reduced QOL. Sociodemographic factors were found to be correlated with QOL. Despite the considerable impact of demographic factors on patient expectations, our study challenges the expected mediation role of the pharmacist-patient relationship and counseling time on medication adherence. Nevertheless, patient expectations partially mediated the relationship between sociodemographic characteristics and QOL.

Conclusion

This study sheds light on the intricate dynamics between patient characteristics, health status, medication adherence, and QOL within the context of the patient-pharmacist relationships.

Utilization rates and predictors of sodium glucose cotransporter 2 inhibitor use in patients with heart failure with or without type 2 diabetes

PURPOSE

Sodium glucose cotransporter 2 (SGLT2) inhibitors have been demonstrated to reduce cardiovascular deaths and heart failure (HF) hospitalizations in patients with HF. Despite this, utilization remains low. The purpose of this study was to characterize SGLT2 inhibitor utilization rates and predictors of use in a population of patients with or without type 2 diabetes (T2D).

METHODS

This was a retrospective, single-center, descriptive chart review study. Individuals 18 years of age or older with HF were eligible for inclusion. Charts were reviewed between August 2021 and February 2022. The primary objective was to identify rates of SGLT2 inhibitor prescribing for patients with HF within a large academic medical center. Logistic regression analyses were conducted to identify potential SGLT2 inhibitor utilization predictors (demographic characteristics, medical history, laboratory results, specialty provider visits, medication use, and medication coverage).

RESULTS

A total of 800 patients with HF were included: 377 with HF with reduced ejection fraction (HFrEF), 88 with mildly reduced EF, and 335 with preserved EF. Key baseline characteristics were as follows: 43% female; 47% Hispanic; 42% with T2D; 49% with established atherosclerotic cardiovascular disease; and mean age, 65 years. SGLT2 inhibitor utilization was 6.5% overall. Key predictors of utilization were as follows: T2D (odds ratio [OR], 33.4; 95% CI, 8.01-139.55), HFrEF (OR, 2.8; 95% CI, 1.45-5.51), HF clinic visit (OR, 2.5; 95% CI, 1.40-4.60), visit with pharmacist with prescriptive authority (OR, 5.8; 95% CI, 3.14-10.88), and enrollment in the hospital patient assistance program (OR, 2.3; 95% CI, 1.08-4.97).

CONCLUSION

Despite guideline recommendations, SGLT2 inhibitors are underutilized in patients with HF with or without T2D.

Holistic approach to drug therapy in a patient with heart failure

Heart failure (HF) is a growing global public health problem affecting at least 26 million people worldwide. The evidence-based landscape for HF treatment has changed at a rapid rate over the last 30 years. International guidelines for the management of HF now recommend the use of four pillars in all patients with reduced ejection fraction: angiotensin receptor neprilysin inhibitors or ACE inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose co-transporter-2 inhibitors. Beyond the main four pillar therapies, numerous further pharmacological treatments are also available in specific patient subtypes. These armouries of drug therapy are impressive, but where does this leave us with individualised and patient-centred care? This paper reviews the common considerations needed to provide a holistic, tailored and individual approach to drug therapy in a patient with HF with reduced ejection fraction, including shared decision making, initiating and sequencing of HF pharmacotherapy, drug-related considerations, polypharmacy and adherence.

Impact of Pharmacist-Led Heart Failure Clinic on Optimization of Guideline-Directed Medical Therapy (PHARM-HF)

This prospective study included patients with heart failure (HF) with reduced ejection fraction (HFrEF) with LVEF < = 40% to evaluate the impact of pharmacist on guideline directed medical therapy (GDMT). The primary outcome was to compare proportion of triple GDMT achieved for Angiotensin-Converting-Enzyme-Inhibitors (ACEI)/Angiotensin-Receptor-Blockers (ARB)/Angiotensin-Receptor-Neprilysin-Inhibitors (ARNI), beta-blockers, aldosterone antagonists (AA), and quadruple GDMT which in additional to triple therapy, included Sodium glucose co-transporter 2 inhibitor (SGLT2i) at 90-day post-enrollment compared to baseline. Secondary endpoints included achieving target and/or maximally tolerated ACEI/ARB/ARNI and beta-blockers combined and individually as well as SGLT2i and AA GDMT at 90-day post-enrollment compared to baseline. We also compared combined and individual HF-related hospitalization/emergency room (ER) visits 90 days pre-/post-enrollment. Of the total 974 patients screened, 80 patients seen at least once in the heart failure medication titration clinic (HMTC) were included in the analysis. Median (IQR) age was 71 (57-69) years with majority white male. There was a significant improvement in the proportion of patients who achieved quadruple GDMT (p = 0.001) and triple GDMT (p-value = 0.020) at 90-day post-enrollment compared to baseline. The secondary GDMT outcomes were also significantly increased at 90 days post-enrollment compared to baseline. Significant difference in mean as well as proportion of combined HF-related hospitalization/ER-visits was found 90 days pre-/post-enrollment (p = 0.047). Our study found that pharmacist's intervention increased the proportion of patients who achieved GDMT at 90 days.

The Role of Pharmacists in Providing Pharmaceutical Care in Primary and Secondary Prevention of Stroke: A Systematic Review and Meta-Analysis

Pharmacists deliver pharmaceutical care in many different healthcare settings and are well-placed to support the prevention of stroke. However, their role and impact in this area is ill-defined. This systematic review aims to explore the pharmacists’ role in stroke prevention. Nine databases were searched for studies reporting pharmacist interventions in the management of primary and secondary ischaemic stroke prevention. Study quality was evaluated through Cochrane Risk of Bias and Joanna Briggs Institute (JBI) appraisal tools where possible. A narrative review was conducted and meta-analysis performed for studies with comparable outcomes. Of the 834 initial articles, 31 met inclusion criteria. Study designs were varied and included controlled trials, observational studies, audit reports and conference abstracts. Seven studies addressed the pharmacists’ role in primary prevention and 24 in secondary prevention. Pharmacist interventions reported were diverse and often multifactorial. Overall, 20 studies reported significant improvement in outcomes. Meta-analysis showed pharmacist interventions in emergency care significantly improved the odds of achieving thrombolytic therapy door to needle (DTN) times ≤45 min, odds ratio: 2.69 (95% confidence interval (CI): 1.95−3.72); p < 0.001. The pharmacists’ role is varied and spans the stroke treatment pathway, with the potential for a positive impact on a range of health-related outcomes.

Interdisciplinary Physician-Pharmacist Medication Review for Outpatients With Heart Failure: A Subanalysis of the PHARM-CHF Randomized Controlled Trial

Aims: Patients with chronic heart failure (CHF) require polypharmacy and are at increased risk for drug-related problems. Interdisciplinary physician-pharmacist medication review may improve drug treatment. Our goal was to analyze the changes from the physician-documented medication plan (MP) and patient-stated medication to an interdisciplinary consolidated MP (CMP).

Methods: This pre-specified subanalysis of the PHARM-CHF randomized controlled trial analyzed the medication review of CHF patients in the pharmacy care group. Community pharmacists compared the MP with the drug regimen stated by the patient and consulted with physicians on identified discrepancies and other medication-related problems resulting in a CMP.

Results: We analyzed 93 patients (mean 74.0 ± 6.6 years, 37.6% female), taking a median of ten (IQR 8–13) drugs. 80.6% of patients had at least one change from MP to CMP. We identified changes in 32.7% (303/926) of drugs. The most common correction was the addition of a drug not documented in the MP to the CMP (43.2%). We also determined frequent modifications in the dosing regimens (37.6%). The omission of a drug documented in the MP but left out of the CMP accounted for 19.1%. Comparing patient-stated medication to CMP, the current drug regimen of patients was changed in 22.4% of drugs.

Conclusion: The medication review resulted in changes of medication between MP and CMP in most of the patients and affected one-third of drugs. Structured physician-pharmacist interdisciplinary care is able to harmonize and optimize the drug treatment of CHF patients.

Self-care perception and behaviour in patients with heart failure: A qualitative and quantitative study

Background and objective

Self‐care strategies in heart failure (HF) are effective for disease management, yet adherence in many patients is inadequate. Reasons are presumably multifactorial but remain insufficiently investigated; thus, we aimed to analyse self‐care adherence and associated factors in outpatients with HF.

Methods and results

To measure self‐care levels and explore barriers and facilitators to self‐care adherence in patients with HF, quantitative study using the European Self‐Care Behaviour Scale (EHFScBS‐9) (n = 80; NYHA II–III, mean age 72 ± 10 years, 58% male) and qualitative study using semi‐structured interviews (n = 32; NYHA II–III, mean age 73 ± 11, 63% male) were conducted. We detected lowest adherence to regular exercise (39%) and contacts with healthcare provider in case of worsening symptoms (47%), whereas adherence was highest for regular medication taking (94%). Using the EHFScBS‐9 standardized cut‐off score ≤ 70, 51% of patients reported inadequate self‐care. Binary logistic regression analysis showed significant influence of education (OR = 0.314, 95% CI: 0.103–0.959) and perceived control (OR = 1.236, 95% CI: 1.043–1.465) on self‐care adequacy. According to the situation‐specific theory of HF self‐care, most commonly reported factors affecting the process of self‐care were knowledge about HF self‐care behaviours (84%), experience with healthcare professionals (84%), beliefs about their expertise (69%) and habits related to medication taking (72%). Among values, working responsibilities (53%) and maintenance of traditions (31%) appeared as the most prevalent socially based values affecting motivation for self‐care. Situational characteristics related to the person (self‐confidence, 53%; adaptive coping strategies, 88%), problem (burdensome breathing difficulties, 56%; co‐morbidities, 81%) and environment (practical support from family/caregivers, 59%; financial difficulties, 50%) were also commonly reported.

Conclusions

Various factors, including health‐related beliefs, habits and socially based values, need to be taken into account when planning self‐care interventions in patients with HF. A patient tailored approach should be based on adequate patient evaluation, taking into consideration the particular personal and social context.

The impact of pharmacist/physician care on quality of life in elderly heart failure patients: results of the PHARM-CHF randomized controlled trial

Aims

Patients with heart failure (HF) have impaired quality of life (QoL). The randomized controlled trial PHARM‐CHF investigated whether an interdisciplinary intervention consisting of regular contacts with the community pharmacy and weekly dosing aids improves medication adherence in patients with HF. It is unknown how an intervention involving frequent structured pharmacy visits affects QoL. Our aim was to explore adherence to the intervention and effects on QoL.

Methods and results

Among 237 patients, n = 110 were randomized to pharmacy care and n = 127 to usual care. The pharmacy care group received a medication review followed by (bi‐)weekly dose dispensing and counselling. The median follow‐up was 2.0 years [inter‐quartile range (IQR) 1.2–2.7]. Median interval between pharmacy visits was 8.4 days (IQR 8.0–10.3) and the visits lasted in median 14 min (IQR 10–15). Median adherence to the intervention was 96% (IQR 84–100). QoL at 365 days was predefined as a main secondary and at 730 days as another secondary endpoint in PHARM‐CHF. QoL was measured by the Minnesota Living with Heart Failure Questionnaire; and for 111 patients (n = 47 in the pharmacy care group and n = 64 in the usual care group), data were available at baseline, and after 365 and 730 days (mean age 74 years; 41% female). Improvement in QoL was numerically higher in the pharmacy care group after 365 days and was significantly better after 730 days (difference in total scores −7.7 points [−14.5 to −1.0]; P = 0.026) compared to the usual care group. In all subgroups examined, this treatment effect was preserved. Improvements in the physical and emotional dimensions were numerically higher in the pharmacy care group after 365 days and were significantly better after 730 days: −4.0 points [−6.9 to −1.2]; P = 0.006, and −1.9 points [−3.7 to −0.1]; P = 0.039, respectively.

Conclusions

A pharmacy‐based interdisciplinary intervention was well received by the patients and suggests clinically important improvements in QoL.