A Review of the Role of the Pharmacist in Heart Failure Transition of Care

Assessment of a Geriatric Evaluation and Management in the Home (GEMITH) Service at a Quaternary Hospital: A Retrospective Observational Study

Background: The increasing aging population in Australia has created a higher demand for specialist geriatric services within hospitals. A Geriatric Evaluation and Management in the Home (GEMITH) service was implemented at a quaternary Queensland hospital. The GEMITH service was unique as it incorporated a specialist pharmacist into the multidisciplinary team. Objective: To determine the medication safety and quality impact of the GEMITH service by evaluating the type and clinical significance of specialist pharmacist interventions. Methods: This was retrospective observational study of clinical interventions made by the GEMITH pharmacist for patients admitted to the service between October 2020 to April 2021. All pharmacist interventions were rated for their clinical significance using the Society of Hospital Pharmacists of Australia (SHPA) risk classification system. The ratings were undertaken by a panel of three pharmacists that independently assessed the interventions, coming together for final discussion. A narrative analysis of the interventions were derived through group consensus. Results: There was a total of 119 admissions to the GEMITH service, with 132 clinical interventions made by the specialist geriatric pharmacist. The majority (47%) of interventions were considered as low risk interventions, although high- (21%) and extreme-risk (2%) interventions still occurred. The most common type of intervention (32%) involved medication reconciliation. Other intervention types included monitoring recommendations, dosing interventions, and deprescribing suggestions. Conclusion: Multiple clinical interventions were made by the GEMITH pharmacist, which prevented possible and significant medication-related harm. This demonstrated the quality impact of the specialist pharmacist in improving medication safety for geriatric patients.

Development of hospital pharmacy services at transition of care points: a scoping review

BACKGROUND

Several hospital pharmacy services exist, which take place at different interfaces of patient care. Although they are an important tool for improving medication safety, they are not yet sufficiently implemented in hospitals around the world.

OBJECTIVE

This scoping review aims to summarise different hospital pharmacy services at transition of care (TOC) points in order to identify development trends and practice patterns in high-income countries over the past decade.

METHODS

A literature search of four databases (PubMed, PubPharm, Cochrane Library (Ovid) and ScienceDirect) since 2011 was conducted. A detailed search strategy was developed and refined with the help of a research librarian. Title, abstract and full-text selection was carried out by two researchers independently. The study was reported in accordance with the PRISMA-ScR items to ensure quality standard reporting. Only studies originating from developed countries and published in the English language were included. The data obtained were extracted and summarised using a data extraction form developed to meet the research aims of the study.

RESULTS

Of the 5456 search results, 65 studies met the inclusion criteria. These originated from Europe (n=29), North America/Canada (n=28), Australia (n=7) and Asia (n=1). Individual TOC services such as medication reconciliation and medication review on admission and at discharge were the main focus of published literature practice patterns between 2011 and 2016, after which a more holistic TOC service started to emerge that follows patients across all TOC points during their hospital stay. Facilitators and barriers were consistently dependent on resources and infrastructure. Clinical and economic outcomes show a mixed picture.

CONCLUSION

During the past decade pharmaceutical services have developed more holistic TOC services. Large-scale high-quality studies are needed to reliably determine clinical and economic benefit.

Optimizing Heart Failure Management: A Review of the Clinical Pharmacist Integration to the Multidisciplinary Health Care Team

Heart failure (HF) stands as a prevalent chronic ailment, imposing a substantial burden on global healthcare systems due to recurrent hospitalizations, intricate management, persistent symptoms, and polypharmacy challenges. The augmentation of patient safety and treatment efficacy across various care stages, facilitated by a multidisciplinary HF team inclusive of a clinical pharmacist, emerges as paramount. Evidence underscores that the collaborative engagement of a physician and a clinical pharmacist engenders proficient and secure management, forestalling avoidable adversities stemming from drug reactions and prescription inaccuracies. This synergistic approach tailors treatments optimally to individual patients. Post-discharge, the vulnerability of HF patients to re-hospitalization looms large, historically holding sway as the foremost cause of 30-day readmissions. Diverse strategies have been instituted to fortify patient well-being, leading to the formulation of specialized transitional care programs that shepherd patients effectively from hospital to outpatient settings. These initiatives have demonstrably curtailed readmission rates. This review outlines a spectrum of roles assumed by clinical pharmacists within the healthcare cohort, spanning inpatient care, transitional phases, and outpatient services. Moreover, it traverses a compendium of studies spotlighting the affirmative impact instigated by integrating clinical pharmacists into these fields.

Exploration of current pharmacy practice in cardio-oncology: Experiences & perspectives

INTRODUCTION

Cardiovascular complications can occur in oncology patients secondary to certain cancer therapies. Pharmacists are involved in the care of oncology patients who are at risk of or experiencing cardiotoxicity related to their cancer therapy. Our study aimed to understand how pharmacists in Canada care to these patients and to explore their experiences, perceptions, and challenges.

METHODS

Canadian pharmacists currently involved in the care of patients receiving cancer treatments and at risk of or experiencing cardiotoxicity were invited to participate in a 30-min telephone interview using an interview guide. A combination of inductive and deductive reasoning was applied using two coders who independently reviewed the transcribed interviews and identified key concepts and themes.

RESULTS

Eight pharmacists were interviewed. Perceived benefits included sharing specialized knowledge and conducting safety assessments. Perceived challenges were the lack of role recognition and resources and fractured continuity of care. Proposed future directions were to play a more substantial role in direct medication management, creation of specific guidance and tools to support the clinical decision-making process, and to understand how pharmacists at other sites were providing care through the creation of a community of practice.

CONCLUSIONS

As patient-focused medication specialists, pharmacists help guide clinical decision-making, assess cardiac risk factors, and offer individualized education to meet the holistic needs of oncology patients at risk of or experiencing cardiotoxicities. The creation of a cardio-oncology community of practice may allow pharmacists with a common interest to connect, share learnings, and collaborate on how to continue to advance the delivery of care.

Heart failure drug classes and 30-day unplanned hospital readmission among patients with heart failure in Ethiopia

BACKGROUND

Drug therapy is a crucial aspect of heart failure management and has been shown to reduce morbidity and mortality in heart failure patients. However, the comparative effects of these drug classes on readmission rates have not been well studied. Therefore, the aim of this study was to examine the association between different classes of heart failure drugs and 30-day readmission rates in patients with heart failure.

METHOD

A multicenter, hospital-based retrospective cohort design was employed and 572 randomly selected patients with heart failure were included. Data were entered in Epi-data version 4.6 and analyzed with STATA version 17. Kaplan-Meier and log-rank tests were used to estimate and compare survival time. A Cox proportional hazard model was utilized, employing both bi-variable and multi-variable analyses, to examine the effect of predictors on the timing of unplanned hospital readmissions. The strength of the association was assessed using an adjusted hazard ratio (aHR), and statistical significance was declared for p-values < 0.05 and a 95% confidence interval (CI).

RESULTS

In this study, a total of 151 (26.40%) heart failure patients were readmitted within 30 days of discharge. In the multivariate cox proportional hazards analysis being an age (> 65 year) (AHR: 2.34, 95%CI: 1.63, 3.37), rural in residency (AHR: 1.85, 95%CI: 1.07, 3.20), hospital stays > 7 Days (AHR: 3.68, 95%CI: 2.51,5.39), discharge with Diuretics (AHR: 2.37, 95%CI: 1.45, 3.86), and discharge with Beta-Blocker (AHR: 0.48, 95%CI: 0 0.34, 0.69) were identified as independent predictors of unplanned hospital readmission.

CONCLUSION

Elderly patients, being in rural areas, longer hospital stays, and discharges of patients on diuretics and not on beta-blockers were independent predictors of unplanned hospital readmission. Therefore, working on these factors will help to reduce the hazard of unplanned hospital readmissions, improve patient outcomes, and increase the efficiency of heart failure management.

Cardiac intensive care unit: where we are in 2023

Cardiac intensive care has been a constantly evolving area of research and innovation since the beginning of the 21st century. The story began in 1961 with Desmond Julian's pioneering creation of a coronary intensive care unit to improve the prognosis of patients with myocardial infarction, considered the major cause of death in the world. These units have continued to progress over time, with the introduction of new therapeutic means such as fibrinolysis, invasive hemodynamic monitoring using the Swan-Ganz catheter, and mechanical circulatory assistance, with significant advances in percutaneous interventional coronary and structural procedures. Since acute cardiovascular disease is not limited to the management of acute coronary syndromes and includes other emergencies such as severe arrhythmias, acute heart failure, cardiogenic shock, high-risk pulmonary embolism, severe conduction disorders, and post-implantation monitoring of percutaneous valves, as well as other non-cardiac emergencies, such as septic shock, severe respiratory failure, severe renal failure and the management of cardiac arrest after resuscitation, the conversion of coronary intensive care units into cardiac intensive care units represented an important priority. Today, the cardiac intensive care units (CICU) concept is widely adopted by most healthcare systems, whatever the country's level of development. The main aim of these units remains to improve the overall morbidity and mortality of acute cardiovascular diseases, but also to manage other non-cardiac disorders, such as sepsis and respiratory failure. This diversity of tasks and responsibilities has enabled us to classify these CICUs according to several levels, depending on a variety of parameters, principally the level of care delivered, the staff assigned, the equipment and technologies available, the type of research projects carried out, and the type of connections and networking developed. The European Society of Cardiology (ESC) and the American College of Cardiology (ACC) have detailed this organization in guidelines published initially in 2005 and updated in 2018, with the aim of harmonizing the structure, organization, and care offered by the various CICUs. In this state-of-the-art report, we review the history of the CICUs from the creation of the very first unit in 1968 to the discussion of their current perspectives, with the main objective of knowing what the CICUs will have become by 2023.

Transitional Care in Patients with Heart Failure: A Concept Analysis Using Rogers' Evolutionary Approach

Objective

The purpose of this study was to clarify the concept of transitional care in patients with heart failure.

Background

Transitional care is increasingly being applied in patients with heart failure, but the concept of transitional care in heart failure patients is not uniform and confused with other definitions, which limits further research and practice on transitional care for these patients.

Design

Rodgers' evolutionary concept analysis.

Methods

A comprehensive literature search was conducted using the PUBMED, EMBASE, EBSCO, Chinese Biological Medicine (CBM), CNKI, and WANFANG databases (up to January 26, 2023). We used Rodgers' evolutionary concept analysis method to identify related concepts, attributes, antecedents, and consequences of transitional care in patients with heart failure.

Results

A total of 33 articles were included. The following attributes belonging to transitional care in patients with heart failure were extracted from the literature: self-care, multidisciplinary collaboration, and information transmission. The antecedents were patients' health status, the health literacy of patients and caregivers, the role functions of the main implementer and social and medical resources. Consequences were separated into two categories: patient-centered health outcomes (all-cause mortality, health-related quality of life, discharge preparedness, self-care behaviors, satisfaction of patients) and healthcare utilization outcomes (hospital readmission, length of hospital stay, emergency department visits).

Conclusion

This study found that transitional care in heart failure patients is a systemic care process during a vulnerable period that improves patient self-management and coordination between hospital resources and social support systems for continuous management to promote smooth patient transitions between different locations. This concept analysis will inform healthcare providers in designing evidence-based interventions and quality improvement strategies to ensure that transition processes lead to desired outcomes. In addition, this study will also be helpful for developing specific assessment tools to identify patients with HF who need transitional care.

Long-term use of triple antibiotic-induced black hairy tongue: A case report

Black hairy tongue is a rare condition, characterized by a black discoloration and hair-like structure appearing on the dorsal surface of the tongue. The mechanism of black hairy tongue remains unclear but could be predisposed by multiple factors. We described a case of a 53-year-old Chinese female with a diagnosis of bronchiectasis complicated with Mycobacterium abscessus infection, and a triple antibiotic regimen was prescribed for the infection. One month later, a black hairy tongue appeared. The clinical pharmacist was consulted to investigate the association of medication-related factors by the attending clinician, and the clinical pharmacist identified the potential cause and suggested an appropriate treatment for the black hairy tongue. The black hairy tongue disappeared and did not recur during subsequent treatment.

The Pharmacy of the Future: Pharmacy Professionals' Perceptions and Contributions Regarding New Services in Community Pharmacies

The use of information and communication technologies (ICTs) has revolutionized the provision of health services, often referred to as eHealth, benefiting community pharmacies that can offer new services in innovative formats, namely through telepharmacy. This study aimed to explore the perceptions of pharmacy professionals (i.e., pharmacists and pharmacy technicians) on the provision of new services. The study consisted of administering an online questionnaire to pharmacy professionals nationwide. The questionnaire was developed by the research team, based on focus group methodology, from which an inductive analysis led to the categories that made up the dimensions of the survey. Participants were 95 pharmacy professionals with a mean age of 33.69 years old (SD = 10.75). Almost 79% were women. The results show overall receptivity to the development of new services in community pharmacies. Suggestions for the development of the new services, conditions necessary for their implementation, potential obstacles, and strategies to promote adherence to the new services, among others, are identified. The knowledge thus acquired will help community pharmacies to develop innovative solutions in counselling, pharmacotherapy monitoring, and pharmacovigilance, for example, of herb/dietary supplement-drug adverse reactions and interactions. Based on this information, new services can become more accessible, namely through the use of ICTs.

Heart Failure: Priorities for Transition to Home

Nurses play a key role in promoting successful transitions of patients with heart failure (HF) from the hospital to the ambulatory setting. Engaging patients and caregivers in discharge teaching early in the hospitalization can enhance their understanding of HF as a clinical syndrome and identify precipitants of decompensation. Effective transitional care interventions for patient with HF include a phone call within 48 to 72 hours and a follow-up appointment within 7 days. Early symptom identification and treatment are key aspects of HF care to improve quality of life and minimize risk of hospitalization.

Effect of clinical pharmacists participating in nutritional therapy for patients with acute cerebral infarction complicated with dysphagia

Objective

To explore the effect of clinical pharmacists participating in nutritional therapy for patients with acute cerebral infarction (ACI) complicated with dysphagia.

Methods

This is a Clinical comparative study. A total of 82 patients with ACI complicated with dysphagia treated in Baoding No.1 Central Hospital from May 2021 to February 2022 were included as subjects. They were divided into control group (n= 40, without clinical pharmacists) and experimental group (n= 42, with clinical pharmacists) using a random number table. The effect of nutritional therapy and the incidence of adverse reactions were compared between the two groups.

Results

In the experimental group, PALB and ALB were both higher than those in the control group on the seven and 14-day after treatment (p< 0.05), while HB was higher than that in the control group only on the 14-day after treatment (p< 0.05). After treatment for 14-day, MAMC and TSF in the experimental group were higher than those in the control group (p< 0.05), while NIHSS score was lower than that in the control group (p< 0.05). The incidence of adverse events in the experimental group was lower than that in the control group (p< 0.05).

Conclusion

Pharmaceutical intervention in nutritional therapy for patients with ACI complicated with dysphagia has positive significance in further improving the nutritional status and nutritional indexes, enhancing the efficacy of drug treatment and reducing the risk of adverse events, and is worthy of promotion.

The Impact of Prescribing Monitoring Policy on Drug Use and Expenditures in China: A Multi-center Interrupted Time Series Study

BACKGROUND

A prescribing monitoring policy (PMP) was implemented in November 2015 in Anhui province, China, the first province to pilot this policy to manage the use and costs of select drugs based on their large prescription volumes and/ or costs in hospitals. This study evaluated the impact of PMP on the use and expenditures of different drugs in three tertiary hospitals in Anhui.

METHODS

We obtained monthly drug use and expenditures data from three tertiary hospitals in Anhui (November 2014 through September 2017). An interrupted time series (ITS) design was used to estimate changes in defined daily doses (DDDs per month) and drug expenditures (dollars per month) of policy-targeted and non-targeted drugs after PMP implementation. Drugs were grouped based on whether they were recommended (recommended drugs) by any clinical guidelines or not (non-recommended drugs), or if they were potentially over-used (proton pump inhibitors, PPIs).

RESULTS

After PMP, DDDs and costs of the targeted PPIs (omeprazole) declined while use of non-targeted PPIs increased correspondingly with overall sustained declines in total PPIs. The policy impact on recommended drugs varied based on whether the targeted drugs have appropriate alternatives. The DDDs and costs of recommended drugs that have readily accessible appropriate alternatives (atorvastatin) declined, which offset increases in its alternative non-target drugs (rosuvastatin), while there was no significant change in those recommended drugs that did not have appropriate alternative drugs (clopidogrel and ticagrelor). Finally, the DDDs and costs of non-recommended drugs decreased significantly.

CONCLUSION

PMP policy impact was not the same across different drug groups. PMP did help contain the use and costs of potentially over-used drugs and non-recommended drugs. PMP did not seem to reduce the use of first-line therapeutic drugs recommended by clinical treatment guidelines, especially those lacking alternatives; such drugs are unlikely appropriate candidates for PMP.

A systematic review of behaviour change techniques in pharmacist-delivered self-management interventions towards patients with chronic obstructive pulmonary disease

BACKGROUND

Self-management interventions often employ behaviour change techniques in order to produce desired target behaviours that are necessary for day-to-day living with a chronic disease. Despite the large number of self-management interventions for patients with chronic obstructive pulmonary disease (COPD), previously reported interventions have been typically delivered by healthcare providers other than the pharmacist.

OBJECTIVE

This systematic review examined the components of pharmacists-delivered COPD self-management interventions according to an established taxonomy of behaviour change techniques (BCTs).

METHODS

A systematic search was conducted on PubMed, ScienceDirect, OVID, and Google Scholar from January 2011 to December 2021 for studies of pharmacist-delivered self-management interventions in COPD patients.

RESULTS

A total of seventeen studies of intervention were eligible for inclusion in the narrative review. Interventions were educational and were delivered individually and face-to-face for the first session. Across studies, pharmacists spent an average of 35 min on the first meeting and had an average of 6 follow-up sessions. Recurrent BCTs in pharmacist interventions were "Information on the health consequence", "Feedback on behaviour", "Instruction on how to perform a behaviour", "Demonstration of the behaviour" and "Behavioural practice/rehearsal".

CONCLUSIONS

Pharmacists have provided interventions towards improving health behaviours, especially on adherence and usage of inhaler devices for patients with COPD. Future self-management interventions should be designed using the identified BCTs for the improvement of COPD self-management and disease outcomes.

Questionnaire survey on pharmacists' roles among non- and health care professionals in medium-sized cities in Japan

Although the scope of pharmacists' work has expanded in Japan, people's perception of this is unclear. To contribute to medical care together with non- and health care professionals, clarifying the perceptions of these groups is important to best utilize pharmacist professionals. We conducted a cross-sectional questionnaire survey among non-health care professionals (n = 487) and nurses (n = 151), medical doctors (n = 133), and pharmacists (n = 204) regarding the work of pharmacists. The questionnaire comprised 56 items in four categories associated with the roles of pharmacists. For each questionnaire item, we performed logistic regression analysis to compare pharmacists' opinions with those of other professionals and non-health care professionals. Opinions were similar between pharmacists and nurses or medical doctors regarding "collecting patient information" and "providing drug information to patients." However, there were differences in perceptions regarding "medical collaboration" (nurses; 8/23 items, physicians; 11/23 items) and "community medicine" (nurses; 9/15 items, physicians; 11/15 items), and pharmacists themselves perceived greater roles related to health care collaboration and community health care. Perceptions of non-health care professionals were poorer than those of pharmacists in all categories (47/56 items). These results suggest that pharmacists must actively communicate to help others understand their specialty and build trusting relationships to improve patient care.

Sodium-Glucose Cotransporter-2 (SGLT-2) Inhibitors Use among Heart Failure Patients and the Role of Pharmacists in Early Initiation of Therapy

Heart failure (HF) is a growing major public health and economic concern in the United States and worldwide. Heart failure mortality rates can be as high as 75% despite advances in therapies. HF is expected to be the fastest growing among all cardiovascular diseases, with HF-associated direct medical costs projected to nearly double over the next 10 years. Hospital admissions, re-admission, and medical cost are a huge burden to the healthcare system, and this is estimated to have increased gradually over the past decades despite the available advances in HF treatment and prevention. Many heart failure therapies have shown improvement in terms of mortality, morbidity, and symptomatic management. Guideline-directed medical therapy (GDMT) for heart failure has proven its ability to reduce morbidity and mortality by 66%. GDMT is recommended to be used among all HF patients when appropriate. In recent years, two new drug classes, angiotensin receptor-neprilysin inhibitor (ARNi) and sodium-glucose cotransporter-2 (SGLT-2) inhibitors, were approved by the United States Food and Drug Administration (US FDA) for the management of heart failure. The exact mechanism by which the SGLT-2 inhibitors attenuate the inflammatory process remains unclear. Several mechanisms have been suggested related to the cardiovascular benefit of SGLT-2 inhibitors, including a reduction in inflammation, improvement in natriuresis/diuresis, and promotion of the use of ketones as a secondary energy source. Clinical data showed that SGLT-2 inhibitors have morbidity and mortality benefits within 30 days of initiation. Studies have proven that clinical pharmacists practicing in HF inpatient and outpatient settings resulted in a reduction of HF hospitalization and an increase in the uptake of GDMT by initiating or up-titrating GDMT agents as well as providing patient education.

Evaluating Pharmacist-Led Heart Failure Transitions of Care Clinic: Impact of Analytic Approach on Readmission Rate Endpoints

Studies evaluating pharmacist-led transitions of care (TOC) services for heart failure patients reported profound decreases in hospital readmissions. Most studies restricted their analysis to clinic attendees (as-treated analysis), which can introduce selection and immortal time bias. In this study, we evaluated the impact of including only clinic attendees vs all clinic referrals in assessing the effectiveness of a pharmacist-led heart failure transitions of care (PharmD HF TOC) clinic program on 30-day readmissions. This is a retrospective, observational study of patients discharged from a heart failure hospitalization at a large urban academic medical center from August 2016 to December 2018. Primary exposure was the provision of a PharmD HF TOC clinic appointment in the intent-to-treat analysis and the attendance of the clinic in the as-treated analysis. Primary outcome was all-cause readmissions within 30 days of discharge. There were 766 and 1015 patients included in the as-treated and intent-to-treat analyses, respectively. In the as-treated analysis, 30-day all-cause readmissions were significantly lower in the intervention group compared to the control group (12.4% vs 19.6%, P = 0.018). In contrast, the intent-to-treat analysis did not reveal a significant difference in 30-day all-cause readmissions between the intervention group and the control group (18.2% vs 19.6%, P = 0.643). Pharmacist-led heart failure TOC program is associated with a reduction in 30-day all-cause readmissions only when restricting the analysis to clinic attendees. Future studies evaluating the effectiveness of post-discharge TOC services need to carefully consider the biases inherent in the evaluation methods employed.

Novel pictograms to improve pharmacist understanding of the number needed to treat (NNT)

INTRODUCTION

Number needed to treat (NNT) is a clinically useful "yardstick" used to gauge the efficacy of therapeutic interventions. The objective of this project was to develop and pilot a series of pictograms and assess their impact on pharmacist understanding of the NNT.

METHODS

Three decision aids containing NNT pictograms were developed following a preliminary literature review and three focus groups with current Australian-registered pharmacists and pharmacist interns. Pharmacists then tested the pictograms in a research pilot in clinical encounters until (1) ≥ 3 sessions had occurred or (2) a two-week period had elapsed from commencement. Knowledge assessment was administered both pre- and post-pilot. Transcription and inductive thematic analysis were applied to focus group data. Descriptive statistics, Wilcoxon signed rank, and McNemar's tests were used to analyse the pilot data.

RESULTS

Six core themes regarding NNT decision aid development were identified with >80% consensus across three focus groups (N = 11). Comparison of the pre-post measures (n = 10) showed an increase in median scores after use of NNT decision aids, correlating to a moderate Cohen classified effect size (d = 0.54). Wilcoxon matched pairs test demonstrated a statistically insignificant influence of NNT pictograms on the knowledge assessment survey (P > .05).

CONCLUSIONS

While the NNT is not a new concept, its incorporation as part of pictograms for health practitioner enrichment is novel. This pilot study suggests that utilizing decision aids with NNT pictograms as counselling adjuncts appears promising in the realm of enhancing pharmacists' understanding of the NNT.

Cardiovascular drug interventions in the cardio-oncology clinic by a cardiology pharmacist: ICOP-Pharm study

Background

Cardio-oncology is a rapidly growing field that requires a novel service design to deal with the increasing number of patients. It is reported that the volume of patients at the cardio-oncology clinic in the United Kingdom is 535 patients/5 years and in Canada is 779 patients/7 years. The pharmacist has a role in reducing the consultation time of physicians.

Objective

To identify the role of a qualified cardiology pharmacist at the cardio-oncology clinic using a new paradigm based on complementary interventions with the cardiologist for the management of patients with cancer and cardiovascular risk factors and/or cardiovascular diseases (CVRF/CVD).

Methods

A prospective observational study was conducted at the cardio-oncology clinic in the Medical City in Baghdad, Iraq between December 2020 and December 2021. Patients with CVRF/CVD were registered. The Iraqi Cardio-Oncology Program-Pharmacist (ICOP-Pharm) paradigm was designed to involve a qualified cardiology pharmacist for initial cardiovascular (CV) drug interventions.

Results

Among 333 patients who attended our clinic over the 1-year interval, 200 (60%) CVRF/CVD cases were enrolled in the study, and of them 79 (40%) patients had CV drug interventions. A total of 196 interventions were done, including 147 (75%) cases performed by the cardiology pharmacist, and 92 (63%) of the latter were CV drug initiations. Among the total CVRF/CVD treated initially by the cardiology pharmacist, hypertension 32 (26%) and cancer therapy-related cardiac dysfunction 29 (24%) were the main types.

Conclusion

The qualified cardiology pharmacist was responsible for three-quarters of the initial CV drug interventions at the cardio-oncology clinic in a complementary approach to the cardiologist. The role of the cardiology pharmacist in the ICOP-Pharm paradigm may be one of the reasons for the ability of the heart team to manage 3-fold of the patient volume when compared with those in the United Kingdom or Canada.

An Up-to-Date Article Regarding Particularities of Drug Treatment in Patients with Chronic Heart Failure

Since the prevalence of heart failure (HF) increases with age, HF is now one of the most common reasons for the hospitalization of elderly people. Although the treatment strategies and overall outcomes of HF patients have improved over time, hospitalization and mortality rates remain elevated, especially in developed countries where populations are aging. Therefore, this paper is intended to be a valuable multidisciplinary source of information for both doctors (cardiologists and general physicians) and pharmacists in order to decrease the morbidity and mortality of heart failure patients. We address several aspects regarding pharmacological treatment (including new approaches in HF treatment strategies [sacubitril/valsartan combination and sodium glucose co-transporter-2 inhibitors]), as well as the particularities of patients (age-induced changes and sex differences) and treatment (pharmacokinetic and pharmacodynamic changes in drugs; cardiorenal syndrome). The article also highlights several drugs and food supplements that may worsen the prognosis of HF patients and discusses some potential drug-drug interactions, their consequences and recommendations for health care providers, as well as the risks of adverse drug reactions and treatment discontinuation, as an interdisciplinary approach to treatment is essential for HF patients.

Identify Early and Involve Everyone: Interdisciplinary Comprehensive Care Pathway Developed for Inpatient Management and Transitions of Care for Heart Failure Patients Reported Using SQUIRE 2.0 Guidelines

Introduction

Heart failure accounts for 1-2% of overall healthcare costs. While the link between re-hospitalization and mortality is unclear, care pathways that standardize inpatient management and establish outpatient follow-up improve patient outcomes and reduce morbidity.

Aim

To implement a comprehensive interdisciplinary care pathway for heart failure patients with the goal of optimizing inpatient management and improving transitions of care.

Methods

To address this clinical need, New York-Presbyterian Brooklyn Methodist Hospital (NYP-BMH) identified resources needed to optimize patient care, developed an inpatient admission order set (so-called “power plan”), and implemented a multidisciplinary clinical care pathway. The Plan-Do-Study-Act cycle addressed the implementation obstacles. Interdisciplinary rounds guided day-to-day management and addressed barriers. Our team developed a sustainable care pathway, and measured the utilization of pharmacy, nutrition, physical therapy, case management, and social work resources; outpatient appointments were made prior to discharge. We used the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines to guide our planning and evaluation of this quality improvement initiative.

Results

Our intervention markedly increased the number of heart failure hospitalizations that were identified on admission, and the use of pharmacy/nutrition services was greater after the intervention. The utilization of our “power plan” promoted adherence to a series of evidence-based best practices, but these measures had no significant impact on readmissions as a whole. The involvement of the case management support team increased outpatient appointments made for patients prior to discharge and aided in the transition of care from inpatient to outpatient management.

Conclusion

The management of heart failure patients starts in the hospital and continues in the community. Patients who are treated in a standardized dedicated care pathway have reduced morbidity and better outcomes. Identifying these patients early, involving a comprehensive team, and transitioning their care to the outpatient setting improves the quality of care in these patients.

Impact of a pharmacist in an interdisciplinary post-cardiac intensive care unit clinic

BACKGROUND

The complex needs of cardiac patients shortly after discharge from a cardiac intensive care unit (CICU) provides a unique opportunity for a pharmacist to help optimize medication management and guideline-directed medical therapy (GDMT).

OBJECTIVE

This study describes the impact of a pharmacist in a multidisciplinary post-CICU clinic.

METHODS

We performed a retrospective cohort study of patients ≥18 years of age who completed a visit in the University of Michigan Post Intensive Cardiac Care Outpatient Long-Term Outreach (PICCOLO) Clinic from July 2018 to May 2020.

RESULTS

One hundred and six CICU survivors were referred. Of these 12 chose to follow-up with long term care providers. A total of 70 of the remaining 94 (74%) completed a visit. The median age was 65 (54-72) years, 71.4% were male, and 85.7% were Caucasian. The median number of pharmacist interventions at each visit was 4 (3-5), all patients had at least 1 intervention. Interventions included medication dose adjustment (n = 46); GDMT optimization (n = 42); medication change (n = 18); medication addition (n = 23) and cessation (n = 21); lab monitoring (n = 97); refill assistance (n = 16); pillbox provision (n = 8); and medication cost assistance (n = 8).

CONCLUSIONS

Pharmacist led interventions in a post CICU clinic resulted in medication changes to optimize therapy, increased laboratory monitoring, medication cost savings for patients, and interventions to facilitate GDMT adherence.

Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: A systematic review of randomized trials and non-randomized intervention studies

BACKGROUND

Polipharmacy has been identified as a contributing factor to the high hospital readmission rates of heart failure (HF) patients. Nevertheless, there limited evidence on pharmacist-led intervention on the reduction of inappropriate medication use in patients.

OBJECTIVE

To summarize the available evidence resulting from interventions, led by pharmacists (alone or as part of a professional team), aimed at reducing inappropriate medications in patients with heart failure.

METHODS

A systematic review was conducted using MEDLINE through PubMed, Embase, the Cochrane Library and Scopus until June 2020. We reviewed both randomized controlled trials and non-randomized intervention studies.The quality of evidence was assessed in accordance with the modified Cochrane Collaboration tool to assess risk of bias for randomized controlled trials. The search and extraction process followed PRISMA guidelines.

RESULTS

Of the 4367 records screening, 9 studies were included in the analysis. In 4 (44.4%) studies, the intervention was carried out by a pharmacist working together with a physician; in 4 (44.4%) the intervention was carried out by a pharmacist alone, and in 1 study, the pharmacist collaborated with a nurse. Only 5 (55.5%) studies described the utilization of guidelines or recommendations to carry out the deprescription, and 3 of these showed improved clinical outcomes in the interventional group compared to the control group. The other studies (4, 44.4%) did not follow a specific guideline or recommendation to evaluate the appropriateness of medication, and none of them showed statistically significant differences in clinical outcomes between interventional and control groups.

CONCLUSION

Only those studies where pharmacists evaluated the appropriateness of treatment to specific HF guidelines showed significant differences in patients' clinical outcomes. The development and validation of a specific tool to evaluate medication appropriateness in patients with HF, could contribute to the improvement of patient health.

Implementation of a pharmacist-led transitional care clinic

PURPOSE

To describe a pharmacist-led transitional care clinic (TCC) for high-risk patients who were recently hospitalized or seen in the emergency department (ED).

SUMMARY

The Memphis Veterans Affairs Medical Center (VAMC) established a pharmacist-led face-to-face and telephone follow-up TCC to improve posthospitalization follow-up care through medication optimization and disease state management, particularly for veterans with high-risk disease states such as chronic obstructive pulmonary disease (COPD) and heart failure (HF). The clinic's clinical pharmacy specialists (CPSs) ordered diagnostic and laboratory tests, performed physical assessments, and consulted other providers and specialty services in addition to performing medication reconciliation, compliance assessment, and evaluation of adverse drug events. TCC patients were typically seen within 2 weeks of discharge and subsequently referred back to their primary care provider or a specialty care provider for continued management. A retrospective review of 2016 TCC data found that 7.8% of patients seen in the TCC were readmitted within 30 days of discharge; readmission rates for COPD and HF were reduced to 13% and 10%, respectively, compared to hospital-wide readmission rates of 17% and 24%. A separate observational analysis found that 30-day readmissions for COPD and HF were reduced in TCC patients, with pharmacists documenting an average of 6.2 interventions and 3.3 medication-related problems per patient. To reduce clinic appointment no-shows, the CPSs worked with inpatient providers and schedulers to emphasize to patients the importance of clinic attendance; also, TCC services were expanded to include telehealth appointments to increase access for rural and/or homebound patients.

CONCLUSION

A pharmacist-led TCC effectively reduced readmissions and prevented medication-related problems for high-risk patients who were hospitalized or seen in the ED.

Impact of a pharmacist-based multidimensional intervention aimed at decreasing the risk of hyperkalemia in heart failure patients: A Latin-American experience

AIMS

Hyperkalemia is a potentially life-threatening condition associated with the use of heart failure (HF) medications, which can lead to increased morbidity and mortality. Novel approaches for hyperkalemia prevention are needed, especially in limited-resource settings. Despite multiple studies showing the beneficial impact of pharmaceutical-counseling in several outcomes, there is a knowledge-gap regarding its impact on hyperkalemia prevention.

METHODS

A case-control study was performed in patients from the Adult Heart Failure Clinic Registry in our institution. Cases were selected using a definition of serum potassium K+ ≥5.5 mmol/L. To study the association between hyperkalemia and relevant risk factors, we performed a multivariate logistic regression analysis using the Least Absolute Shrinkage and Selection Operator (LASSO) method for variable selection. We also fitted a Classification and Regression Tree (CART) to establish complex interactions and effect modifiers between the selected variables.

RESULTS

We matched 483 controls (eligible HF patients without hyperkalemia) to 132 cases (eligible HF patients with hyperkalemia based on age and calendar, yielding a total sample size of 615 patients (270 females) for this study. Cases had statistically significant lower odds of receiving a pharmacist-based multidimensional intervention (PBMI) (OR 0.57; 95% CI, 0.43-0.80) or having HF with reduced ejection fraction (OR 0.56; 95% CI, 0.18-0.72). On the other hand, patients who presented hyperkalemia had statistically significant higher odds of having a history of chronic kidney disease stage 4 (OR 4.97; 95% CI, 2.24-11.01) or 5 (OR 6.73; 95% CI, 1.69-26.84) and being on enalapril at doses =40 mg/day (OR, 9.90; 95% CI 5.81-16.87).

CONCLUSIONS

PBMI is a practical approach to prevent hyperkalemia in HF patients in a limited-resource setting. However, clinical trials are needed to assess its effectiveness.

Influence of polypharmacy on patients with heart failure with preserved ejection fraction: a retrospective analysis on adverse outcomes in the TOPCAT trial

BACKGROUND

Polypharmacy is common in heart failure (HF), whereas its effect on adverse outcomes in patients with HF with preserved ejection fraction (HFpEF) is unclear.

AIM

To evaluate the prevalence, prognostic impacts, and predictors of polypharmacy in HFpEF patients.

DESIGN AND SETTING

A retrospective analysis performed on patients in the Americas region (including the US, Canada, Argentina, and Brazil) with symptomatic HF and a left ventricular ejection fraction ≥45% in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial, an international, randomised, double-blind, placebo-controlled study conducted during 2006-2013 in six countries.

METHOD

Patients were categorised into four groups: controls (<5 medications), polypharmacy (5-9 medications), hyperpolypharmacy, (10-14 medications), and super hyperpolypharmacy (≥15 medications). The outcomes and predictors in all groups were assessed.

RESULTS

Of 1761 participants, the median age was 72 years; 37.5% were polypharmacy, 35.9% were hyperpolypharmacy, and 19.6% were super hyperpolypharmacy, leaving 7.0% having a low medication burden. In multivariable regression models, three experimental groups with a high medication burden were all associated with a reduction in all-cause death, but increased risks of HF hospitalisation and all-cause hospitalisation. Furthermore, several comorbidities (dyslipidemia, thyroid diseases, diabetes mellitus, and chronic obstructive pulmonary disease), a history of angina pectoris, diastolic blood pressure <80 mmHg, and worse heart function (the New York Heart Association functional classification level III and IV) at baseline were independently associated with a high medication burden among patients with HFpEF.

CONCLUSION

A high prevalence of high medication burden at baseline was reported in patients with HFpEF. The high medication burden might increase the risk of hospital readmission, but not the mortality.

Heart Failure Prescribing Quality at Discharge from a Critical Care Unit in Egypt: The Impact of Multidisciplinary Care

Discharge prescriptions for heart failure (HF) patients may not adhere to the clinical practice guidelines. This study aimed to assess the impact of the clinical pharmacist as a member of a multidisciplinary team on the quality of prescribing to HF patients at discharge from a Critical Care Unit (CCU) in Egypt. This was a retrospective cohort study of HF patients discharged from the CCU between January 2013 and December 2017. Guideline Adherence Index (GAI-3) was used to assess guideline-directed prescribing at discharge. Multidisciplinary care was introduced to the CCU on 1 January 2016. The study included 284 HF patients, mean (±SD) age 66.7 ± 11.5 years, 53.2% male. Heart failure with reduced ejection fraction affected 100 patients (35.2%). At discharge, loop diuretics were prescribed to 85.2% of patients; mineralocorticoid receptor antagonists to 54.9%; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers to 51.4%; and β-blockers to 29.9%. Population Guideline Adherence Index (GAI-3) was 45.5%. High-GAI was prescribed to 136 patients (47.9%). Patients with High-GAI were younger; less affected by chronic kidney disease and had fewer comorbidities than those without High-GAI. Prescription of β-blocker increased (24.1% vs. 38.6%, p < 0.001) and digoxin utilization decreased (34.7% vs. 23.7%, p < 0.049) after the introduction of the multidisciplinary care. The inclusion of a clinical pharmacist in the multidisciplinary care team may have a role in optimizing the prescribing of HF guideline-directed therapies at discharge from this setting.

A nurse practitioner-led effort to reduce 30-day heart failure readmissions

BACKGROUND

Heart failure (HF) affects over 6.5 million Americans and is the leading reason for hospital admissions in patients over the age of 65. Readmission rates within 30 days are 21.4% nationally, and 12% of those are likely preventable. Veterans are especially vulnerable to developing cardiac diseases requiring hospitalization and subsequent readmission.

LOCAL PROBLEM

The Southern Arizona Veterans Administration Health Care System has over 5,600 patients diagnosed with HF and a 30-day readmission rate of 21.65%. The aim of this quality improvement project was to reduce 30-day all-cause readmissions by 1% over 8 weeks.

METHODS

To reduce HF readmissions, the plan-do-study-act rapid-cycle method of quality improvement was used.

INTERVENTIONS

A dedicated multidisciplinary HF clinic was formed with a cardiology nurse practitioner, clinical pharmacists, and a dietician. A veteran-centered shared decision-making tool for setting self-care goals was implemented.

RESULTS

The readmission rate of patients seen in the multidisciplinary clinic (n = 33) was reduced by 0.2%. The percentage of veterans seen within 14 days increased from 30% to 54.5%. The average number of days between discharge and cardiology follow-up improved from 45 to 19 days. Veterans were able to set at least one self-care goal 87% of the time. Patient satisfaction with the multidisciplinary clinic was high at 93%.

CONCLUSIONS

Implementing a dedicated, multidisciplinary HF clinic reduced readmissions, improved timeliness of visits, and was well received. Use of a veteran-centered patient engagement tool resulted in more veterans setting self-care goals.

Evaluation of human immunodeficiency virus curricular content in schools of pharmacy in the United States

INTRODUCTION

Human immunodeficiency virus (HIV) is an important educational topic for student pharmacists given extended patient life expectancy and expanding pharmacist roles in HIV treatment and prevention. Data are lacking in regard to curricular content and type of training received by faculty to provide didactic and experiential HIV training.

METHODS

A cross-sectional, population-based survey of United States (US) pharmacy schools was conducted using a 15-item questionnaire. HIV content experts were surveyed at 135 four-year, accredited programs.

RESULTS

Thirty-seven responses were received from schools in the Midwestern (34%), Northeastern (26%), Southern (26%), and Western (14%) regions. Time devoted to didactic HIV education ranged from 0.5 to 60 hours. The majority of respondents (78%, n = 29) reported 10 or fewer hours of HIV-related content, with 41% (n = 15) reporting five or less hours of content. Experiential practice sites for HIV training were variable, with a majority (80%) including an outpatient infectious diseases/HIV clinic. Eighty percent of respondents also reported students receiving fewer than 25 encounters with people living with HIV (PLWH) throughout their entire experiential training. Over half (54%) of respondents reported that the primary HIV instructor devoted four hours per week or less to HIV care.

CONCLUSIONS

Diversity in the amount of time devoted to HIV didactic education existed among reporting US pharmacy schools. Few schools have dedicated faculty spending a substantial amount of time in direct care of PLWH. Minimum standards for HIV education in schools of pharmacy should be established.

Major Cardiac-Psychiatric Drug-Drug Interactions: a Systematic Review of the Consistency of Drug Databases

PURPOSE

Major depressive disorder (MDD) and anxiety disorders (AD) are both highly prevalent among individuals with arrhythmia, ischemic heart disease, heart failure, hypertension, and dyslipidemia. There should be increased support for MDD and AD diagnosis and treatment in individuals with cardiac diseases, because treatment rates have been low. However, cardiac-psychiatric drug interaction can make pharmacologic treatment challenging.

METHODS

The objective of the present systematic review was to investigate cardiac-psychiatric drug interactions in three different widely used pharmacological databases (Micromedex, Up to Date, and ClinicalKey).

RESULTS

Among 4914 cardiac-psychiatric drug combinations, 293 significant interactions were found (6.0%). When a problematic interaction is detected, it may be easier to find an alternative cardiac medication (32.6% presented some interaction) than a psychiatric one (76.9%). Antiarrhythmics are the major class of concern. The most common problems produced by these interactions are related to cardiotoxicity (QT prolongation, torsades de pointes, cardiac arrest), increased exposure of cytochrome P450 2D6 (CYP2D6) substrates, or reduced renal clearance of organic cation transporter 2 (OCT2) substrates and include hypertensive crisis, increased risk of bleeding, myopathy, and/or rhabdomyolysis.

CONCLUSION

Unfortunately, there is considerable inconsistency among the databases searched, such that a clinician's discretion and clinical experience remain invaluable tools for the management of patients with comorbidities present in psychiatric and cardiac disorders. The possibility of an interaction should be considered. With a multidisciplinary approach, particularly involving a pharmacist, the prescriber should be alerted to the possibility of an interaction. MDD and AD pharmacologic treatment in cardiac patients could be implemented safely both by cardiologists and psychiatrists.

TRIAL REGISTRATION

PROSPERO Systematic Review Registration Number: CRD42018100424.

Impact of a Pharmacist-Driven Poststroke Transitions of Care Clinic on 30 and 90-Day Hospital Readmission Rates

BACKGROUND

Stroke impacts nearly 800,000 people annually and the risk of recurrent stroke and hospital readmission is increased early following the initial event. Due to the increase in morbidity and mortality associated with secondary events, a pharmacist-driven poststroke transitions of care clinic was created at Methodist University Hospital to provide risk factor modification in an effort to decrease risk of recurrence and hospital readmissions.

METHODS

A retrospective matched-cohort study was conducted between 9/1/2017 and 2/28/2019. Adult patients with a primary diagnosis of stroke, discharged to home, and attended a poststroke transitions of care clinic visit were included. Patients were matched on the basis of age ±3 years, race, gender, and type of stroke to those who did not receive pharmacist intervention during the same time period. The primary endpoint was 30-day hospital readmissions. Secondary endpoints included 90-day readmissions, 30 and 90-day emergency department visits, and recurrent stroke rates. Type and quantity of pharmacist interventions was also assessed.

RESULTS

One hundred and eighty-eight patients were included in the analysis. Baseline differences existed between the groups in the following: history of transient ischemic attack, stroke severity score, and insurance status. No significant difference was found in 30-day readmissions. There was a significant difference found in 90-day readmissions (5.3% versus 21.3%, P = .001). There were no significant differences in emergency department utilization at 30 or 90 days or stroke recurrence rates. Pharmacists made a mean of 3.5 interventions made during each visit.

CONCLUSIONS

Although the primary goal to reduce 30-day readmission was not met, a pharmacist-driven poststroke transitions of care clinic significantly decreased 90-day hospital readmission rates.

Pharmacy: Addressing substance use in the 21st century

Across all care environments, pharmacists play an essential role in the care of people who use and misuse psychoactive substances, including those diagnosed with substance use disorders. To optimize, sustain, and expand these independent and collaborative roles, the Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) has developed core competencies for pharmacists to address substance use in the 21st century. Key concepts, skills, and attitudes are outlined, with links to entrustable professional activities to assist with integration into a variety of ideally interdisciplinary curricular activities.

Impact of Heart Failure Transitions of Care Program: A Prospective Study of Heart Failure Education and Patient Satisfaction

Purpose: The purpose of the study is to evaluate the impact of heart failure medication education on 30-day all-cause readmission rates and patient-reported satisfaction scores. Methods: This single-center pilot study was conducted at a 396-bed tertiary-care hospital in the Midwest from September 2017 to December 2018. For research purposes, patients were divided into 2 groups. The control group was looked at retrospectively and included patients who received education by the nurse educator. The intervention group was reviewed proactively and included patients who received education by a pharmacy student. The purpose of the study was to compare readmission rates among patients who received medication education from pharmacy students with those who received the same education by the heart failure nurse educator. The primary outcome was 30-day all-cause readmission rate among those with a diagnosis of heart failure. The secondary endpoints included patient satisfaction scores by phone survey. The patient satisfaction phone survey was conducted by a single pharmacist 1 week after patient education was provided. Results: For the primary endpoint, there were 222 patients in the treatment group compared with the control group of 941 patients. The treatment group resulted in 30 (13.5%) of the 222 patients being readmitted within 30 days compared with the control group where 186 (19.6%) of the 941 were readmitted (P = .0395). The risk reduction in odds ratio and relative risk of readmission was 0.63 (confidence interval [CI] = 0.42-0.96) for the treatment group and 0.68 (CI = 0.48-0.98) for the control group. For the secondary endpoint, 56 patients were called 1 week after discharge, and there was no significant difference in overall patient satisfaction between groups. Conclusion: This study demonstrated that heart failure medication education provided by the pharmacist or pharmacy student resulted in improved patient outcomes and ultimately a reduction in 30-day all-cause readmission rates.

Impact of Pharmacist Involvement in Heart Failure Transition of Care

Background: Heart failure (HF) transition of care (TOC) programs may improve continuity of care and coordination and decrease hospital readmissions. Objective: This study evaluated the impact of pharmacy-led HF TOC on HF readmission rate. Methods: This was a single-center, pre-post quasi-experimental study. Pharmacy TOC comprised admission and discharge medication reconciliations and patient education. Patients were included if they had a primary HF diagnosis. Patients were excluded if they were admitted for a non-HF diagnosis, admitted for <24 hours, had a stage IV cancer or dementia diagnosis, or were transferred to hospice care. The primary outcome was HF 30-day readmission rate. Results: A total of 663 patients were included in the study: 330 in the control group and 333 in the intervention group. The average age for both groups was 67 ± 16 years; 48.1% were female; 56.9% were African American; and 51.4% of patients had an ejection fraction ≤40%. In the control group, 57 (17.3%) patients had a HF 30-day readmission compared with 35 (10.5%) patients in the intervention group. After adjusting for age, the intervention group continued to show a difference in readmission (odds ratio = 0.578; 95% CI = 0.367-0.911; P = 0.018). The most common interventions were medication addition (11%), dose titration (7.5%), medication discontinuation (6.6%), and duplication avoidance (2.7%). Conclusion and Relevance: Pharmacy-led HF TOC, as a component of a targeted hospital-based initiative, significantly decreased HF 30-day readmission rate. Results from this study warrant further research to explore which interventions in TOC are most effective.

The role of the clinical pharmacist in the prevention of potential drug interactions in geriatric heart failure patients

Background The treatment of heart failure patients is very complex and includes lifestyle modification as well as different pharmacological therapies. Polypharmacy is very common in such patients and they are at increased risk of potential drug-drug interactions and associated effects such as poor adherence, compliance and adverse events. Objective The aim of the present study is to investigate retrospectively the prescribed pharmacotherapy of the hospital discharged heart failure patients for possible drug interactions. Settings Clinic for Cardiology of the "Saint Marina" University Hospital in Varna, Bulgaria. Method Lexicomp^® Drug interaction software was used for screening potential drug-drug interactions. Logistic regression was applied to determine the odds ratio for the association between the age and number of drugs taken and the number of potential drug-drug interactions. Main outcome measure Incidence and type of pDDIs in geriatric heart failure patients. Results A retrospective study was conducted by reviewing the medical records of 248 selected heart failure patients for the prescribed medicines for a 1-year period (January 2015-December 2015). The total number of potential drug-drug interactions was 1532, or approximately 6.28 (± 4.72 SD) per one person. The range of prescribed drugs was between three and fourteen, 92% of them have been taking more than five medicines, an average of 7.12 (± 2.07 SD) per patient. The average age was 72.35 (± 10.16 SD). The results have shown stronger association between the number of drugs taken (more than 7) and the occurrence of potential drug-drug interactions (more than 10)-37.84 (95% CI 9.012-158.896, P ≤ 0.001). No statistically significant differences were found between age and occurrence of potential drug-drug interactions (more than 10)-1.008 (95% CI 0.441-2.308, P = 0.848). Conclusion The incidence of drug-drug interactions in heart failure patients is high. The clinical pharmacist, as a part of the multidisciplinary team, could reduce medication-related problems, such as drug interactions, and to optimize drug therapy by checking the treatment prescribed at the discharge of these patients.

Developing a disease management program for the improvement of heart failure outcomes: the do's and the don'ts

INTRODUCTION

Heart failure is a highly prevalent condition affecting approximately 2% of people worldwide. Heart failure disease management programs (DMP) have shown a reduction in mortality and reduced hospitalization and are an established part of clinical guidelines; however, their presence is not widespread. Focusing on the application of proven therapies, patient education, diagnosis with work up of cause and easy access for clinical deterioration should be fundamental to the structure of the DMP. Multidisciplinary team care with early and timely recognition of potentially critical patients is essential, along with the inclusion of patients diagnosed in hospital as well as the community. Areas covered: The fundamental structure of a DMP along with the current gaps in evidence is outlined. Current challenges with the heart failure condition along with the current best evidence are covered. Articles were searched using MEDLINE containing the keywords; Chronic Heart Failure, Disease Management Program. We have also provided clinical opinion. Expert opinion: A multidisciplinary approach to disease management programs is essential to providing adequate care to patients. DMPs are an established part of current guidelines and should be a benchmark of treatment. Future resources should be focused on identifying patients at risk and early prevention.