Clinical Pharmacy Services in Heart Failure: An Opinion Paper from the Heart Failure Society of America and American College of Clinical Pharmacy Cardiology Practice and Research Network

Impact of clinical pharmacist interventions on economic outcomes in a cardiology setting in Qatar

We sought to investigate the economic impact of preventing adverse events in a cardiology setting in Qatar as an effect of the clinical pharmacist as an intervention. This is a retrospective study of interventions by clinical pharmacists within an adult cardiology setting in a public healthcare setting (i.e Hamad Medical Corporation). The study included interventions that took place in March 2018, July 15, 2018-August 15, 2018, and January 2019. The economic impact was measured via calculating the total benefit, defined as the sum of the cost savings and the cost avoidance. Sensitivity analyses were adopted to confirm the robustness of the results. The pharmacist intervened in 262 patients, resulting in 845 interventions, with appropriate therapy (58.6%) and dosing/administration (30.2%) being the most frequent categories of reported interventions. Cost savings and cost avoidance resulted in QAR-11,536 (USD-3,169) and QAR1,607,484 (USD 441,616), respectively, yielding a total benefit of QAR1,595,948 (USD438,447) per three months and QAR6,383,792 (USD1,753,789) per a year.

Analysis of matrix metalloproteinase-9 levels among acute heart failure patients with ACE inhibitor therapy (Dr. Soetomo Regional General Hospital, Surabaya)

OBJECTIVES

Heart disease is a clinical condition characterized by specific signs such as joint inflammation, weakness, and shortness of breath. Left ventricular remodeling can be experienced by patients with heart failure wherein a change in myocyte and nonmyocyte components occurs. One of the biomarkers in heart disease with myocardial fibrosis is matrix metalloproteinase-9 (MMP-9). Common therapy that is often given to patients with heart failure is ACE inhibitors. This main objective of this research is to investigate the effect of ACE inhibitor therapy on the degrees of MMP-9 as a biomarker among patients with heart disease.

METHODS

This research applied one group pretest-posttest design to analyze the variation in the levels of MMP-9 as a biomarker for heart function. Twenty-three subjects with acute heart disease met that inclusion also exclusion criteria, who were selected using nonrandom sampling. Statistical analysis was conducted to specify the levels of MMP-9 before, after the administration of therapy.

RESULTS

The most widely used ACE inhibitor drug was ramipril for 15 patients (65%), and the least used ACE Inhibitor drug was captopril for two patients (9%). Meanwhile, the mean MMP-9 levels before therapy was (1,915.26 pg/mL ± 260.84), and the mean MMP-9 levels after therapy was (1,916.93 pg/mL ± 383.12). The statistical analysis result revealed no significant difference in the degrees of Matrix Metalloproteinase-9 accumulation (p=0.378).

CONCLUSIONS

There was no significant reduction in the levels of Matrix Metalloproteinase-9 after pretest and posttest.

"When you're homeless, they look down on you": A qualitative, community-based study of homeless individuals with heart failure

BACKGROUND

Outpatient heart failure (HF) care involves intensive self-management (SM). Effective HF SM is associated with improved outcomes. Homelessness poses challenges to successful SM.

OBJECTIVES

To identify the ways in which homelessness may impede successful SM of HF and engagement with the healthcare system.

METHODS

We conducted open-ended, semi-structured interviews with homeless adults with HF. Data were analyzed by a multidisciplinary team using a grounded theory approach.

RESULTS

We interviewed 19 participants, 11 (58%) of whom were homeless at the time of interview. Interviews revealed a combination of influences on HF SM. Major themes included instability and lack of routine, tradeoffs between basic necessities and HF SM, and stigmatization by healthcare providers.

CONCLUSIONS

Anticipatory guidance aimed at the unique challenges faced by homeless individuals with HF may aid successful SM. HF providers should simlpify medication regimes and engage in non-stigmatizing discourse. Larger-scale interventions include the creation of medical respite programs.

Drug-Therapy Problems and Predictors among Hospitalized Heart-Failure Patients: A Prospective Observational Study

BACKGROUND

Heart-failure patients are at high risk of experiencing drug-therapy problems, owing to polypharmacy, comorbidities, and usually advanced age. Drug-therapy problems can lead to poor clinical outcomes, increased health-care costs and decreased quality of life, and thus strategies for identifying, resolving, and preventing them are urgently needed. Therefore, this study aimed at investigating the incidence and predictors of drug-therapy problems among hospitalized heart-failure patients.

METHODS

This hospital-based prospective observational study was conducted from February 1 to May 31, 2014 at Jimma University Specialized Hospital. Patients of either sex aged 18 years and above with chronic heart failure and complete medical records were enrolled. Patients with high-output heart failure, <1 day of hospital stay, unwilling to give written informed consent, and unconscious without caregivers were excluded. Data were collected from medication charts, laboratory reports, patients/caregivers, morning multidisciplinary meetings, and ward rounds. Multivariate binary logistic regression analysis was done to identify independent predictors of drug-therapy problems.

RESULTS

A total of 104 heart-failure patients (mean age 51.20±15.66 years, females 51.9%) were consecutively enrolled, and 95 (91.3%) had experienced at least one drug-therapy problem (total 268, mean 2.82±1.39 encounters per patient). Of these problems, 45.5% were the need for additional drugs, followed by noncompliance (22.0%), inappropriate dosing (9.3%), unnecessary drugs (9.0%), ineffective drugs (8.2%), and adverse drug reactions (6.0%). None of the independent variables was found to be an independent predictor of having at least one drug-therapy problem. However, the number of clinical/pharmacological risk factors (AOR 7.93), female sex (AOR 3.24), and length of hospital stay (AOR 12.98) were predictors of noncompliance.

CONCLUSION

Patients suffered from a large number of drug-therapy problems. Drugs with survival benefit were underused. Noncompliance and the need for additional drug therapy were the most frequently identified drug-therapy problems. Numbers of clinical/pharmacological risk factors, length of hospital stay, and female sex were identified as predictors for noncompliance.

Potentially Inappropriate Prescriptions in Heart Failure with Reduced Ejection Fraction (PIP-HFrEF)

Heart failure (HF) is a chronic debilitating and potentially life-threatening condition. Heart Failure patients are usually at high risk of polypharmacy and consequently, potentially inappropriate prescribing leading to poor clinical outcomes. Based on the published literature, a comprehensive HF-specific prescribing review tool is compiled to avoid medications that may cause HF or harm HF patients and to optimize the prescribing practice of HF guideline-directed medical therapies. Recommendations are made in line with the last versions of ESC guidelines, ESC position papers, scientific evidence, and experts' opinions.

A Mobile App (mHeart) to Detect Medication Nonadherence in the Heart Transplant Population: Validation Study

Background

Medication nonadherence in heart transplant recipients (HTxR) is related to graft loss and death. mHeart is a mobile app that uses electronic patient-reported outcome measures (ePROMs) to identify and manage medication nonadherence in the outpatient heart transplant (HTx) population.

Objective

The study primarily aimed to validate mHeart to measure medication nonadherence in early stage HTxR by assessing the psychometric properties of ePROMs. The secondary aims were to (1) measure patient satisfaction with the mHeart tool and its usability and (2) explore the impact of a theory-based treatment on medication nonadherence rates to determine its scalability to larger research.

Methods

A prospective study was conducted in the outpatient clinic of a tertiary hospital. All consecutive early stage HTxR (<1.5 years from HTx) were included. The ePROM psychometric properties assessed were validity, reliability, responsiveness, interpretability, and burden. ePROMs comprised the 4-item Morisky-Green-Levine questionnaire and an adapted version of the Haynes-Sackett questionnaire. The Simplified Medication Adherence Questionnaire (SMAQ) was also applied on-site. Three consecutive medication nonadherence assessments were performed by a transplant pharmacist. To improve medication nonadherence, theory-based interventions were delivered in a 1-month period. Patient satisfaction was assessed by a semiquantitative Web-based survey at the end of the study.

Results

We included 31 early stage HTxR (age: mean 54 years, SD 12 years), and 71% (22/31) of them were men. The HTxR were taking a mean 13 (SD 4; range 7-18) drugs per day. A total of 42% (13/31) of patients were unaware of the consequences of medication nonadherence, and 39% (12/31) of patients were nonadherent to immunosuppressive treatment. The content validity measure showed excellent levels of expert panel agreement for the Haynes-Sacket (14/14, 100%) and Morisky-Green-Levine (13/14, 93%) questionnaires. SMAQ and Morisky-Green-Levine ePROMs showed similar measurement domains (convergent validity, phi=0.6, P<.001), which, as expected, differed from Haynes-Sackett ePROMs (divergent validity, phi=0.3, P=.12). Reliability assessment revealed a very strong association between ePROM and on-site PROMs (phi>0.7, P<.001). Reproducibility was moderate (Haynes-Sackett κ=0.6, P<.002) or poor (Morisky-Green-Levine κ=0.3, P=.11) because of unexpected improved medication adherence rates during the test-retest period. According to responsiveness, the theory-based multifaceted intervention program improved medication nonadherence by 16% to 26% (P<.05). A burden analysis showed that ePROMs could potentially overcome traditional on-site limitations (eg, automatic recording of ePROM responses in the hospital information system). The mean score for overall patient satisfaction with the mHeart approach was 9 (SD 2; score range: 0-10). All 100% (29/29) of patients surveyed reported that they would recommend the mHeart platform to other HTxR.

Conclusions

ePROMs adhered to the quality standards and successfully identified medication nonadherence in the HTx population, supporting their widespread use. The theory-based intervention program showed a promising improvement in medication adherence rates and produced excellent patient satisfaction and usability scores in HTxR.

Evaluating Pharmacist Impact on Guideline-Directed Medical Therapy in Patients With Reduced Ejection Fraction Heart Failure

BACKGROUND

Limited literature exists evaluating the ability of a pharmacist to quickly and effectively initiate and manage dose titrations of guideline-directed medication therapy (GDMT) in an outpatient setting.

METHODS

This pilot study aimed to investigate the impact of pharmacist-managed, outpatient heart failure management on patients' heart failure outcomes, and health-care-related costs. Retrospective chart review performed on patients referred to pharmacist practicing under collaborative practice agreement. End points included time to achieve individualized target doses of GDMT; beta-blocker dose tolerance; and the clinic's impact on left ventricular ejection fraction (LVEF), hospital admission, and emergency department encounter rates. Descriptive statistics were used to report nominal data. Wilcoxon signed-rank test was used to evaluate continuous variables.

RESULTS

Thirty-six patients completed full titration utilizing an average of 4.9 visits over 12.7 weeks. Seventy-eight percent (n = 28) achieved full beta-blocker titration. Seventy-six percent of patients had LVEF >35% after titration versus 43% at baseline. A significant reduction in all-cause hospital admissions was seen during both 13-week and 12-month comparison periods (P < .05). We estimated >US$50 000 annual revenue generation from 0.2 full-time equivalent pharmacist.

CONCLUSIONS

Although hypothesis generating, our results support the idea that pharmacist-managed medication titration clinics are effective at completing titration, improving LVEF, and generating revenue.

Evaluation of discharge prescriptions for secondary prevention in patients with acute coronary syndromes in Iraq

Background:

Optimal prescribing of secondary prevention medications after acute coronary syndrome (ACS) events has been shown to reduce morbidity and mortality. However, it is unknown whether these medications are optimally prescribed at discharge from acute care in Iraq.

Objective:

To evaluate whether patients with ACS received optimal secondary prevention medications: antiplatelets, statins, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARBs), and beta-blockers at discharge from a cardiology unit, and to assess whether statins, ACEI/ARBs and beta-blockers were prescribed at target doses based on the American Heart Association/American College of Cardiology (AHA/ACC) guidelines.

Methods:

Observational retrospective cross-sectional study of patients with ACS admitted to a hospital in Baghdad and survived to discharge between May 2016 and January 2017. Patient-level data and secondary prevention medications at discharge were extracted from routine medical records. Optimal dosing was defined as ≥75%, moderate dosing as 50–74%, and low dosing as <50% of the target dose.

Results:

45.6% (200/439) of eligible patients were included in the study who were aged 25 to 90 years (mean 57.8 years) with 78.0% (156/200) being male. Of those included, 84.5% had a myocardial infarction and 15.5% unstable angina, and the length of hospital stay ranged from 1 to 29 days (median 4 days). In total, 53.5% of patients were prescribed all five secondary prevention medications at discharge, and after accounting for contraindications, 60.0% were treated according to AHA/ACC guidelines. The prescription rate of dual antiplatelet therapy, statins, ACEI/ARBs and beta-blockers was 92.5%, 94.5%, 69.5% and 87.0% respectively. Hypertension, diabetes mellitus and the prescription of oral nitrates were associated with the prescription of optimal secondary prevention therapy. Although 80.9% of patients were prescribed target doses of antiplatelets and statins, only 12.2% and 9.2% were prescribed target doses of ACEI/ARBs, and beta-blockers respectively.

Conclusions:

Approximately one in two patients received the recommended secondary prevention therapy. However, only a minority of patients were prescribed optimal doses of ACEI/ARBs and beta-blockers, in line with guidance. Quality improvement strategies should be implemented, which may include greater involvement of pharmacists within the cardiology multidisciplinary team.

Patient-reported barriers to medication adherence in heart failure in Scotland

OBJECTIVES

Medication adherence is the end result of a complex set of interwoven factors. Non-adherence with medication in heart failure patients is associated with excess mortality and morbidity. Studies describing interventions to improve adherence in heart failure are limited by a lack of robust methods and inconsistent outcomes. The aim of this evaluation was to explore the barriers to medication adherence in Scottish heart failure patients in order to inform the development of complex interventions.

METHODS

Qualitative patient interviews. Participants were aged ≥18 years with current or previous signs or symptoms of clinical heart failure, reduced left ventricular ejection fraction ≤45% and confirmed adherence of <80% in tablet counts of heart failure therapy. Thematic analysis was employed.

KEY FINDINGS

Eleven patients were recruited. The median age was 79 years old, and participants were typically from socially deprived communities. Participants were prescribed a mean 9.9 different medications per day. Seven distinct themes emerged around barriers to medication adherence: co-morbidity; treatment burden; health literacy; trust in NHS; socioeconomic factors; autonomy and health expectations.

CONCLUSIONS

The factors affecting medication adherence in heart failure are multi-factorial and are unlikely to be improved by one single-faceted intervention. Future interventions need to treat patients holistically, build their trust as partners, simplify complex treatment regimens where possible and involve educational and social elements. The skill set and opportunities afforded to pharmacists may be well placed to deliver many of these aspects but this would need tested in the context of the development of complex interventions.

A competency framework for clinical pharmacists and heart failure

Objectives

Heart failure is an escalating ‘pandemic’ with malignant outcomes. Clinical pharmacist heart failure services have been developing for the past two decades. However, little clarity is available on the additional advanced knowledge, skills and experience needed for pharmacists to practice safely and competently. We aimed to provide an expert consensus on the minimum competencies necessary for clinical pharmacists to deliver appropriate care to patients with heart failure.

Methods

There were four methodological parts; (1) establishing a project group from experts in the field; (2) review of the literature, including existing pharmacy competency frameworks in other specialities and previous heart failure curricula from other professions; (3) consensus building, including developing, reviewing and adapting the contents of the framework; and (4) write-up and dissemination to widen the impact of the project.

Key findings

The final framework defines minimum competencies relevant to heart failure for four different potential levels of specialism: all pharmacists regardless of role (Stage 1); all patient-facing clinical pharmacists (Stage 2); clinical pharmacists with specific planned roles in the care of heart failure patients (Stage 3); and regionally/nationally/internationally recognised expert pharmacists with a direct specialism in heart failure (Stage 4).

Conclusions

The framework delivers the vital first step needed to help standardise care, give pharmacists a blueprint for career progression and continuing professional development and bring clarity to the role of the pharmacist. Future collaboration between professional bodies and training providers is needed to develop structured programmes to align with the framework and facilitate training and resultant accreditation.

Current perspectives on the role of the pharmacist in heart failure management

Pharmacists play an important role within a multidisciplinary health care team in the care of patients with heart failure (HF). It has been evaluated and documented that pharmacists providing medication reconciliation especially during transition of care, educating patients on their medications, and providing collaborative medication management lead to positive changes in the patient outcomes, including but not limited to decreasing in hospitalizations and read-missions. It is foreseeable that pharmacist roles will continue to expand as new treatment and innovative care are developed for HF patients. I reviewed published role of pharmacists in the care of HF patients. MEDLINE and Current Content database (both from 1966 – December 31, 2017) were utilized to identify peer-reviewed clinical trials, descriptive studies, and review articles published in English using the following search terms: pharmacists, clinical pharmacy, HF, and cardiomyopathy. Citations from available articles were also reviewed for additional references. Preliminary search revealed 31 studies and 55 reviews. They were further reviewed by title and abstract as well as full text to remove irrelevant articles. At the end, 24 of these clinical trials and systematic reviews are described in the following text and Table 1 summarizes 16 pertinent clinical trials. Some roles that are currently being explored include medication management in patients with mechanical circulatory support for end-stage HF, where pharmacokinetics and pharmacodynamics of medications can change, medication management in ambulatory intravenous diuretic clinics, and comprehensive medication management in patients’ home settings. Pharmacists should continue to explore and prospectively evaluate their role in the care of this patient population, including documenting their interventions, and impact to economic and patient outcomes.

Outcomes of a Pharmacist-Managed Heart Failure Medication Titration Assistance Clinic

Background: National guidelines recommend angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) and β-blockers (BBs) at target doses for morbidity and mortality benefits in heart failure with reduced ejection fraction (HFrEF); regardless, titration of these therapies in practice remains suboptimal. We implemented an outpatient pharmacist-managed HFrEF medication titration assistance clinic (MTAC) at one institution to improve titration for general cardiology (GC) patients. Objective: To evaluate MTAC impact by determining the proportion of patients on target or maximum tolerated ACE inhibitor/ARB and BB doses. Methods: A retrospective chart review of adult patients with documented ejection fraction ≤40% managed in the MTAC or GC from 2011 to 2013 was conducted. HFrEF medication regimens were collected at initial visit and months 1, 2, 3, 6, 9, and 12 to assess titration. Target doses were defined per guideline or dose at which ejection fraction recovered during the study. Maximum tolerated doses were defined as the highest dose patients tolerated without physiological limitations. Results: Of 148 patients, the MTAC managed 51 and GC managed 97. At baseline, 90% of MTAC versus 82% of GC patients were prescribed ACE inhibitors/ARBs and BBs. In the MTAC, 4% were at target or maximum tolerated doses compared with 32% of GC patients ( P < 0.001). At 12 months, 95% of patients in the MTAC and 87% in GC were prescribed ACE inhibitors/ARBs and BBs. Of those prescribed ACE inhibitors/ARBs and BBs, 64% in the MTAC versus 40% in GC reached target or maximum tolerated doses ( P = 0.01). Conclusions: The pharmacist-managed MTAC increased the proportion of patients on optimal HFrEF therapies and are a resource for GC patients.

Implementation of a Patient Navigator Program to Reduce 30-day Heart Failure Readmission Rate

With increasing awareness to provide personalized care our institution applied the American College of Cardiology (ACC) Patient Navigator Program to identify hospitalized heart failure (HF) patients and improve transitions and outcomes. Utilizing a Navigator Team (NT) composed of a nurse and clinical pharmacist, we delivered evidenced-based interventions and hypothesized this approach would improve identification of HF inpatients and reduce the 30-day all-cause readmission rate. Patients were followed from admission to discharge and received at least one intervention, tailored to the patient's health literacy and social needs. The 30-day all-cause readmission rate was 17.6% for the Patient Navigator Program and 25.6% for the medical center. Compared to the medical center there was a statistically significant increase in education and follow-up. For patients who received specific NT interventions of education and follow-up the readmission rate was 10.3% and 6.1% respectively. Hospital programs can easily embed a NT into existing initiatives to further reduce the readmission rate.

Integrating New Pharmacologic Agents into Heart Failure Care: Role of Heart Failure Practice Guidelines in Meeting This Challenge

Heart failure is well recognized as a major public health concern not only due to severe and frequent adverse health outcomes but also related to the major financial burden this syndrome presents with advancing age in Western societies. Despite the dire need for more efficacious therapies and better application of existing advances, treatment gaps persist, and outcomes in heart failure remain poor, with continually high mortality and morbidity. Treatment guidelines provide one strategy for advancing quality of care in patients with heart failure. This approach, with well-known potential strengths and weaknesses, has both adherents and detractors. Heart failure treatment guidelines have been in sharp focus recently due to updates that address the United States Food and Drug Administration (FDA) approval in 2015 of two new pharmacologic therapies for heart failure with reduced ejection fraction: sacubitril-valsartan and ivabradine. Our commentary will revisit issues in guideline methodology and discuss these in the context of the updates addressing the FDA approval of new pharmacologic agents for heart failure with reduced ejection fraction.

Incorporation of a community pharmacy-based heart failure assessment tool by advanced pharmacy practice experience students

OBJECTIVES

To incorporate a published clinical tool related to heart failure (HF) assessment into advanced pharmacy practice experiences in the community pharmacy setting to provide a meaningful and innovative learning experience for students.

SETTING

Sixteen independent and chain community pharmacies that served as advanced pharmacy practice experience locations.

PRACTICE DESCRIPTION

Sixteen community pharmacy locations served as rotation sites and participated in data collection (8 chain and 8 independent).

PRACTICE INNOVATION

This was the first study in which pharmacy students used The One-Minute Clinic for Heart Failure (TOM-C HF) tool to assess HF within the community pharmacy setting.

INTERVENTIONS

Trained student pharmacists identified patients who may have heart failure by evaluating medication dispensing records, interviewed the patient using the TOM-C HF tool, and made interventions as clinically appropriate.

EVALUATION

The number of students using the TOM-C HF tool, the number and types of interventions made, and student perceptions about the educational and professional value of the patient interaction.

RESULTS

Thirty-three of 83 (40%) students completed 63 patient assessments. Thirty-five percent of patients (22/63) were candidates for an intervention. Interventions were performed in 9 of 22 patients (41%). More than 65% of students found the patient interaction to have educational and professional value.

CONCLUSION

Students were able to assess HF patients and make interventions in a community pharmacy setting. The majority of students also perceived some value in these assessments. The incorporation of a clinical tool in the community setting driven by fourth-year pharmacy students has been shown to be feasible and to provide both a novel advanced practice experience. In addition, it may be expandable to the services offered at community pharmacies.

Acute Decompensated Heart Failure

Heart failure (HF) is a societal burden due to its high prevalence, frequent admissions for acute decompensated heart failure (ADHF), and the economic impact of direct and indirect costs associated with HF and ADHF. Common etiologies of ADHF include medication and diet noncompliance, arrhythmias, deterioration in renal function, poorly controlled hypertension, myocardial infarction, and infections. Appropriate medical management of ADHF in patients is guided by the identification of signs and symptoms of fluid overload or low cardiac output and utilization of evidence-based practices. In patients with fluid overload, various strategies for diuresis or ultrafiltration may be considered. Depending on hemodynamics and patient characteristics, vasodilator, inotropic, or vasopressor therapies may be of benefit. Upon ADHF resolution, patients should be medically optimized, have lifestyle modifications discussed and implemented, and medication concierge service considered. After discharge, a multidisciplinary HF team should follow up with the patient to ensure a safe transition of care. This review article evaluates the management options and considerations when treating a patient with ADHF.

Computerized pharmaceutical intervention to reduce reconciliation errors at hospital discharge in Spain: an interrupted time-series study

WHAT IS KNOWN AND OBJECTIVE

It is well known that medication reconciliation at discharge is a key strategy to ensure proper drug prescription and the effectiveness and safety of any treatment. Different types of interventions to reduce reconciliation errors at discharge have been tested, many of which are based on the use of electronic tools as they are useful to optimize the medication reconciliation process. However, not all countries are progressing at the same speed in this task and not all tools are equally effective. So it is important to collate updated country-specific data in order to identify possible strategies for improvement in each particular region. Our aim therefore was to analyse the effectiveness of a computerized pharmaceutical intervention to reduce reconciliation errors at discharge in Spain.

METHODS

A quasi-experimental interrupted time-series study was carried out in the cardio-pneumology unit of a general hospital from February to April 2013. The study consisted of three phases: pre-intervention, intervention and post-intervention, each involving 23 days of observations. At the intervention period, a pharmacist was included in the medical team and entered the patient's pre-admission medication in a computerized tool integrated into the electronic clinical history of the patient. The effectiveness was evaluated by the differences between the mean percentages of reconciliation errors in each period using a Mann-Whitney U test accompanied by Bonferroni correction, eliminating autocorrelation of the data by first using an ARIMA analysis. In addition, the types of error identified and their potential seriousness were analysed.

RESULTS AND DISCUSSION

A total of 321 patients (119, 105 and 97 in each phase, respectively) were included in the study. For the 3966 medicaments recorded, 1087 reconciliation errors were identified in 77·9% of the patients. The mean percentage of reconciliation errors per patient in the first period of the study was 42·18%, falling to 19·82% during the intervention period (P = 0·000). When the intervention was withdrawn, the mean percentage of reconciliation errors increased again to 27·72% (P = 0·008). The difference between the percentages of pre- and post-intervention periods was statistically significant (P = 0·000). Most reconciliation errors were due to omission (46·7%) or incomplete prescription (43·8%), and 35·3% of which could have caused harm to the patient.

WHAT IS NEW AND CONCLUSION

A computerized pharmaceutical intervention is shown to reduce reconciliation errors in the context of a high incidence of such errors.

Effectiveness of the clinical pharmacist in reducing mortality in hospitalized cardiac patients: a propensity score-matched analysis

Background

Pharmacist-led medication review services have been assessed in the meta-analyses in hospital. Of the 135 relevant articles located, 21 studies met the inclusion criteria; however, there was no statistically significant difference found between pharmacists’ interventions and usual care for mortality (odds ratio 1.50, 95% confidence interval 0.65, 3.46, P=0.34). These analyses may not have found a statistically significant effect because they did not adequately control the wide variation in the delivery of care and patient selection parameters. Additionally, the investigators did not conduct research on the cases of death specifically and did not identify all possible drug-related problems (DRPs) that could cause or contribute to mortality and then convince physicians to correct. So there will be a condition to use a more precise approach to evaluate the effect of clinical pharmacist interventions on the mortality rates of hospitalized cardiac patients.

Objective

To evaluate the impact of the clinical pharmacist as a direct patient-care team member on the mortality of all patients admitted to the cardiology unit.

Methods

A comparative study was conducted in a cardiology unit of a university-affiliated hospital. The clinical pharmacists did not perform any intervention associated with improper use of medications during Phase I (preintervention) and consulted with the physicians to address the DRPs during Phase II (postintervention). The two phases were compared to evaluate the outcome, and propensity score (PS) matching was applied to enhance the comparability. The primary endpoint of the study was the composite of all-cause mortality during Phase I and Phase II.

Results

Pharmacists were consulted by the physicians to correct any drug-related issues that they suspected may cause or contribute to a fatal outcome in the cardiology ward. A total of 1,541 interventions were suggested by the clinical pharmacist in the study group; 1,416 (92.0%) of them were accepted by the cardiology team, and violation of incompatibilities had the highest percentage of acceptance by the cardiology team. All-cause mortality was 1.5% during Phase I (preintervention) and was reduced to 0.9% during Phase II (postintervention), and the difference was statistically significant (P=0.0005). After PS matching, all-cause mortality changed from 1.7% during Phase I down to 1.0% during Phase II, and the difference was also statistically significant (P=0.0074).

Conclusion

DRPs that were suspected to cause or contribute to a possibly fatal outcome were determined by clinical pharmacist service in patients hospitalized in a cardiology ward. Correction of these DRPs by physicians after pharmacist’s advice caused a significant decrease in mortality as analyzed by PS matching. The significant reduction in the mortality rate in this patient population observed in this study is “hypothesis generating” for future randomized studies.

Clinical-pharmacist intervention reduces clinically relevant drug-drug interactions in patients with heart failure: A randomized, double-blind, controlled trial

BACKGROUND

Incidence of drug-drug interactions (DDIs) increases with complexity of treatment and comorbidities, as in heart failure (HF). This randomized, double-blind study evaluated the intervention of the pharmacist on prevalence of clinically relevant DDIs (NCT01855165).

METHODS

Patients admitted with HF were screened for clinically relevant DDIs, and randomized to control or intervention. All attending physicians received standard advice about pharmacological therapy; those in the intervention group also received alerts about clinically relevant DDIs. Primary endpoint was DDI at discharge and secondary were re-hospitalization or death during follow-up.

RESULTS

Of 213 patients, 51 (mean age, 79 ± 6 years; male, 47%) showed 66 clinically relevant DDIs and were randomized. For intervention (n=26) versus control (n=25), the number of patients with and the number of DDIs were significantly lower at discharge: 8 vs. 18 and 10 vs. 31; p=0.003 and 0.0049, respectively. Over a 6 month follow-up period, 11 control and 9 intervention patients were re-hospitalized or died (p>0.2 for all). No significant differences were seen between control and intervention for patients with eGFR <60 mL/min/1.73 m(2) (78%) for re-hospitalization or death (10 vs. 7; p=0.74).

CONCLUSIONS

Pharmacist intervention significantly reduces the number of patients with clinically relevant DDIs, but not clinical endpoints 6 months from discharge.

Adherence with immunosuppression in heart transplant recipients

PURPOSE OF REVIEW

Nonadherence is a major problem in heart transplantation (htx) and a challenge for clinical practice and research. In heart transplant recipients, nonadherence could cause chronic rejection of the transplanted heart followed by difficult clinical course and/or death of the patient.

RECENT FINDINGS

Main topics are the relationship between psychological aspects and adherence, risk factors and prediction of nonadherence, strategies for improving adherence like single-dose immunosuppressant therapy and follow-up studies.

SUMMARY

There is a lack of behavioral intervention studies. So-called targeted interventions should be defined for clinical practice and research with randomized controlled studies.

Evaluation of a Pharmacist-Managed Heart Failure Education Project: Empowering Patients to Self-Manage Their Disease

Background: Recent reimbursement cuts for hospitals with higher 30-day heart failure (HF)-related readmission rates call for means of reducing those readmissions. Objective: To determine if pharmacist-initiated education increases HF knowledge and assess if an increase in HF knowledge decreases HF readmission. Methods: This was a prospective interventional study. Participants were ≥18 years old admitted through the emergency department of a 322-bed community hospital with a diagnosis and/or past medical history of HF. Terminal/palliative care patients, patients residing in an assisted-living environment, or patients with a mental illness that deemed them incapable of participating were excluded. Forty-eight patients received pharmacist-initiated HF education on HF pathophysiology and its pharmacologic and nonpharmacologic treatment. Medication assistance and ancillary services were consulted when necessary. Patients' knowledge of HF was assessed using the same questionnaire prior to education and through a follow-up phone call within 7 days postdischarge. Results: Posteducation HF knowledge scores were 13.7 points higher than preeducation scores (P < .05). Twenty-five patients (52%) had HF as a primary discharge diagnosis. Of those patients, 9 (36%) were readmitted within 30 days for any cause. Only 3 patients (12%) had a HF-related diagnosis at readmission. There was a statistical difference in the level of knowledge but that was not translated into a statistical difference in readmission rates. Conclusion: Patients' HF knowledge scores increased after pharmacist education. Improvements in HF knowledge could not be correlated with readmission rates. However, the majority of HF patients in this study did not have a HF-related diagnosis at the time of readmission.

Patient risk factors for developing a drug-related problem in a cardiology ward

Background

Because of the high incidence of drug-related problems (DRPs) among hospitalized patients with cardiovascular diseases and their potential impact on morbidity and mortality, it is important to identify the most susceptible patients, who therefore require closer monitoring of drug therapy.

Purpose

To identify the profile of patients at higher risk of developing at least one DRP during hospitalization in a cardiology ward.

Method

We consecutively included all patients hospitalized in the cardiology ward of a teaching hospital in 2009. DRPs were identified through a computerized warning system designed by the pharmacy department and integrated into the electronic medical record.

Results

A total of 964 admissions were included, and at least one DRP was detected in 29.8%. The variables associated with a higher risk of these events were polypharmacy (odds ratio [OR]=1.228; 95% confidence interval [CI]=1.153–1.308), female sex (OR=1.496; 95% CI=1.026–2.180), and first admission (OR=1.494; 95% CI=1.005–2.221).

Conclusion

Monitoring patients through a computerized warning system allowed the detection of at least one DRP in one-third of the patients. Knowledge of the risk factors for developing these problems in patients admitted to hospital for cardiovascular problems helps in identifying the most susceptible patients.

Collaborative Practice Model Between Cardiologists and Clinical Pharmacists for Management of Patients With Cardiovascular Disease in an Outpatient Clinic

The increasing prevalence of cardiovascular disease (CVD) has prompted leading cardiovascular organizations to advocate utilization of a team approach to patient care that includes nonphysician providers. In spite of that, the American College of Cardiology reported that nonphysician providers are underutilized in the management of patients with CVD. A survey of cardiologists revealed that the underutilization is a result of lack of understanding of how best to involve nonphysician providers in the health care team. Clinical pharmacists are one category of nonphysician providers that have recognized effectiveness in managing patients with CVD. No example of a comprehensive model of collaboration between cardiologists and clinical pharmacists is described in the literature that could serve to close this gap in understanding. The objective of this report is to describe a model of cardiologist–clinical pharmacist collaboration in the longitudinal management of patients with CVD that has been successfully implemented in 2 diverse settings. The implementation, evolution, scope of practice, required pharmacist training, logistical elements needed for success, and implementation barriers are reviewed. A summary of the patients referred to the clinic are examined as well.