Pharmacist intervention in the prevention of heart failure for high-risk elderly patients in the community

Medication adherence in adults after hospitalization for heart failure: A cross-sectional study

Background

Medication non-adherence in heart failure (HF) leads to increased mortality, morbidity and healthcare costs. However, no study has investigated HF patients' post-hospitalization medication non-adherence in Switzerland.

Objectives

Our primary aim was to assess the prevalence of post-discharge medication non-adherence in patients with HF. A secondary objective was to identify differences between fully and partially adherent patients regarding selected unplanned therapy-related inpatient/outpatient cardiology visits.

Methods

A non-experimental cross-sectional study was applied. The prevalence of medication adherence was assessed with a German-translated version of the Medication Adherence Report Scale (MARS-5) and analyzed descriptively. Differences between adherent and partially adherent patients' numbers of medications, dosing per day and 180-day unplanned inpatient stays or cardiology outpatient visits were explored.

Results

Of 153 recruited patients, 72 participated in the survey. Of these, 26.4 % were not fully adherent. Their most common reason was forgetfulness (23.7 %). There were no significant group differences regarding therapy-related variables or 180-day unplanned cardiology stays/visits.

Conclusions

Considering that over one-quarter of surveyed HF patients were not fully medication adherent, Swiss cardiology nurses need to be sensitized to this issue and trained in adherence-enhancing interventions. Reaching acceptable adherence levels in patients with HF will require further research and action.

Impact of medication therapy management interventions on drug therapy problems, medication adherence and treatment satisfaction among ambulatory heart failure patients at Tikur Anbessa Specialised Hospital, Addis Ababa, Ethiopia: a one-group pre-post quasi-experimental study

OBJECTIVE

To determine the impact of medication therapy management interventions on drug therapy problems (DTPs), medication adherence and treatment satisfaction among ambulatory heart failure (HF) patients.

STUDY DESIGN, SETTING AND PARTICIPANTS

A one-group pre-post quasi-experimental study was conducted on 423 ambulatory HF patients at Tikur Anbessa Specialised Hospital (TASH), Addis Ababa, Ethiopia. All ambulatory HF patients ≥18 years old attending the adult cardiac clinic of TASH and having a complete medical record and fully met the inclusion criteria were taken as study participants.

INTERVENTIONS

Educational interventions along with a brochure with information on the nature of HF disease and its treatment were provided to study participants. DTPs encountered were resolved by a team of pharmacists and physicians.

RESULTS

In the preintervention phase, 288 DTPs were identified with a mean (SD) of 1.3±1.1. A significant reduction of DTPs (0.67±1.1, p<0.001) was observed in the postintervention phase compared with the preintervention phase. At the postintervention phase, 36.4%, 61.9% and 1.7% of HF patients were highly, medium and low adherent to their treatment regimens, respectively. The total composite score for treatment satisfaction of the study participants was 80.35%.

CONCLUSIONS

The findings of this study demonstrated that by teaming up clinical pharmacists with cardiologists and cardiology fellows, it was possible to reduce the occurrence of DTPs, improve medication adherence and increase treatment satisfaction of HF patients attending at the outpatient cardiac clinic.

Team-based strategies to prevent heart failure

PURPOSE OF REVIEW

The burden of heart failure (HF) in the United States and worldwide is projected to rise. Prevention of HF can curb the burden of this chronic syndrome, but current approaches are limited. This review discusses team-based strategies aimed to prevent HF.

RECENT FINDINGS

Individuals at high risk for developing HF can be identified using HF risk scores, biomarkers, and cardiac imaging. Electronic medical records (EMR) can integrate clinical data to estimate HF risk and identify individuals who may benefit most from preventive therapies. Team-based interventions can lead to enhanced adherence to medications, optimization of medical management, and control of risk factors. Multifaceted interventions involve EMR-based strategies, pharmacist- and nurse-led initiatives, involvement of community personnel, polypills, and digital solutions.

SUMMARY

Team-based strategies aimed to prevent HF incorporate a broad group of personnel and tools. Despite implementation challenges, existing resources can be efficiently utilized to facilitate team-based approaches to potentially reduce the burden of HF.

A Community Pharmacy-Based Intervention in the Matrix of Type 2 Diabetes Mellitus Outcomes (CPBI-T2DM): A Cluster Randomized Controlled Trial

Introduction:

Egypt has the ninth highest diabetes mellitus (DM) prevalence in the world. There is a growing interest in community involvement in DM management.

Aim of the study:

The aim of the study was to evaluate the tailored diabetes care model (DCM) implementation in Alexandria governorate by community pharmacy-based intervention (CPBI) from a clinical, humanistic, and economic aspect.

Methods:

This is a 6-month period cross-over cluster randomized control trial conducted in Alexandria. Ten clusters owing 10 community pharmacies (CPs) recruited 100 health insurance-deprived T2DM patients with >7% HbA1c in 6-months. The study was divided into 2 phases (3 months for each period) with a 1-month washout period in between. After CPs training on DCM, the interventional group received pictorial training for 45 minutes in first visit, and 15 minutes in weekly visits, whereas the control group patients received the usual care (UC). At baseline and end of each phase (3 months), patients had clinical and physical activity assessments, filled all forms of study questionnaire (knowledge, self-management, satisfaction, and adherence) and did all laboratory investigations (Fasting Blood Glucose [FBG]), HbA1c, protein-creatinine clearance (PCR), creatine clearance (GFR), and lipid profile.

Results:

There was no significant difference in the basal systolic and diastolic blood pressure between patients in the CBPI and UC groups, but the CBPI had significantly decreased the mean SBP and DBP by ( P = .008, .040, respectively). Also, significant waist circumference and BMI reductions (−5.82 cm and −1.86 kg/m2, P = .001) were observed in the CBPI. The CBPI patients achieved a greater reduction in FBG and HbA1C than the UC patients (102 mg/dL and 1.9%, respectively P < .001). Also, significant reductions in total cholesterol, LDL, and triglyceride (−6.4, −15.4, and −6.3 mg/dL respectively, P = .001) were achieved in the CBPI group. No significant differences were found in HDL, GFR, and PCR. Moreover, significant improvements of behavior, score of knowledge, self-management, satisfaction, and adherence were observed in CBPI patients. After multivariate analysis, HbA1C readings were significantly influenced by baseline HbA1C and eating habits. The cost saving for CPBI was −1581 LE per 1% HbA1c reduction.

Conclusion:

This is the first study in Egypt that illustrated the positive impact of pictorial DCM delivered by CPBI collaborative care on clinical, humanistic, laboratory, and economic outcomes to local T2DM patients.

Methodological features of quantitative studies on medication adherence in older patients with chronic morbidity: A systematic review

OBJECTIVES

The growing number of chronic, multimorbid older adults encourages healthcare systems to cope with polypharmacy and non-adherence. However, methodology on how to provide effective interventions to enhance medication adherence is still object of debate.

METHODS

To describe methodological features of quantitative studies concerning older adults' medication adherence, by means of a PRISMA systematic review (Scopus, PubMed, Medline). A specific focus was devoted to theoretical models and to the ABC Taxonomy model, as stated by the EMERGE guidelines.

RESULTS

55 papers were included. Most of the studies were conducted using randomized control trials (63.6%) and focused on a single disease only (72.7%). Most of the interventions were provided by a single professional figure (70.9%). Medication adherence was mainly evaluated by means of questionnaires (61.8%) and by clinical records (30.9%). Sixteen studies considered a theoretical model in the intervention framework. The Initiation phase (ABC Taxonomy) was the most neglected.

CONCLUSIONS

Future studies upon medication adherence should account real-life challenges such as multimorbidity, polypharmacy and interdisciplinarity, analyzing adherence as a complex, holistic process.

PRACTICE IMPLICATIONS

Theoretical models may be useful to enhance the soundness of the results, to ease their comparability, to calibrate tailored strategies and to plan patient-centered interventions.

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.

The Effect of Health Education by Pharmacists on 10-Year Atherosclerotic Cardiovascular Disease Risk: A Cluster-Randomized Control Study in a Low Socioeconomic Status Javanese Population

BACKGROUND

Evidence from previous studies demonstrates that lifestyle modification reduces the incidence and complications of atherosclerotic cardiovascular disease. The study aimed to investigate the effect of a lifestyle intervention provided by pharmacists on the 10-year atherosclerotic cardiovascular disease (ASCVD) risk and quality of life (QoL) in a low socioeconomic status Javanese population.

METHODS

This research was a cluster-randomized controlled study of 1-year duration, conducted in a lower social economic community in the Sleman District of Yogyakarta, Indonesia. The eligible subjects were dichotomized into 2 groups: 40 to 55 years (n = 61 vs 65) and 56 to 70 years (n = 21 vs 43) for intervention and control subjects, respectively. The ASCVD score and risk factors within the age-based groups were analyzed using T test/Mann-Whitney test for continuous data or chi-square test for categorical data.

RESULTS

The intervention and control subjects had similar baseline characteristics ( P > .05), including the ASCVD risk with the low- and high-risk classification for younger and elder subjects, respectively. At final follow-up, the younger intervention subjects had lower 10-year ASCVD risk ( P = .001), higher high-density lipoprotein cholesterol ( P = .02), smoking status ( P = .001), persistence rate ( P = .03), and QoL value for the physical and social function domains ( P < .05) than the control subjects, whereas the elder intervention subjects only had better ASCVD risk score than controls ( P = .03). Smoking interacting with intervention was the most influential variable on ASCVD risk in logistic regression analysis.

CONCLUSION

The study demonstrates that the health education by the pharmacists produce significant outcomes of the ASCVD risk, smoking status, and QoL of physical and social function particularly in the younger group.

Clinical outcomes of community pharmacy services: A systematic review and meta-analysis

Community pharmacy services (CPS) have been shown to be positive in many disease management and patient care programs, but clinical outcomes were followed by process indicators and methodological flaws in previous researches made it difficult to prove the effectiveness of clinical outcomes of CPS. Therefore, this study attempted to review the clinical outcomes of CPS. Interventions included are provision of medication review, patient education, adherence assessment, health/lifestyle advice, physical assessment, monitoring, prescribing, or adjusting and administering therapy from community pharmacists. By searching for key words like community pharmacists, pharmaceutical services, clinical outcomes in MEDLINE and EMBASE and manually searching (up to June 2017), 1910 studies investigating the clinical outcomes of CPS were obtained. After screening the titles, abstracts and full texts for relevancy, 52 researches with controlled groups were included and assessed for methodological quality. Finally, 25 studies were selected for the meta-analysis based on their common endpoints: systolic blood pressure, diastolic blood pressure and glycosylated haemoglobin. The Cochrane tool was used to assess the risk of bias. Chi-square and I-square tests were performed to assess heterogeneity, and the weighted mean differences were estimated using random effect models. Of the 52 articles, 47 studies demonstrated that CPS had positive clinical outcomes, 3 studies showed mixed outcomes and 2 studies revealed no effects. In the meta-analysis, intervention groups displayed greater reductions in systolic BP (95% CI: -8.198-2.356), diastolic BP (95% CI: -3.648-0.645) and HbA1c (95% CI: -0.905-0.224) than usual care groups. CPS have positive clinical outcomes, particularly significant reductions in systolic BP, diastolic BP and HbA1c. It was difficult to find out which intervention(s) of CPS directly led to certain changes and influence of CPS might be underestimated for only three common surrogate endpoints. More researches should be conducted with sufficient data.

Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review

BACKGROUND

Polypharmacy, and the associated adverse drug events such as non-adherence to prescriptions, is a common problem for elderly people living with multiple comorbidities. Deprescribing, i.e. the gradual withdrawal from medications with supervision by a healthcare professional, is regarded as a means of reducing adverse effects of multiple medications including non-adherence. This systematic review examines the evidence of deprescribing as an effective strategy for improving medication adherence amongst older, community dwelling adults.

METHODS

A mixed methods review was undertaken. Eight bibliographic database and two clinical trials registers were searched between May and December 2017. Results were double screened in accordance with pre-defined inclusion/exclusion criteria related to polypharmacy, deprescribing and adherence in older, community dwelling populations. The Mixed Methods Appraisal Tool (MMAT) was used for quality appraisal and an a priori data collection instrument was used. For the quantitative studies, a narrative synthesis approach was taken. The qualitative data was analysed using framework analysis. Findings were integrated using a mixed methods technique. The review was performed in accordance with the PRISMA reporting statement.

RESULTS

A total of 22 original studies were included, of which 12 were RCTs. Deprescribing with adherence as an outcome measure was identified in randomised controlled trials (RCTs), observational and cohort studies from 13 countries between 1996 and 2017. There were 17 pharmacy-led interventions; others were led by General Practitioners (GP) and nurses. Four studies demonstrated an overall reduction in medications of which all studies corresponded with improved adherence. A total of thirteen studies reported improved adherence of which 5 were RCTs. Adherence was reported as a secondary outcome in all but one study.

CONCLUSIONS

There is insufficient evidence to show that deprescribing improves medication adherence. Only 13 studies (of 22) reported adherence of which only 5 were randomised controlled trials. Older people are particularly susceptible to non-adherence due to multi-morbidity associated with polypharmacy. Bio-psycho-social factors including health literacy and multi-disciplinary team interventions influence adherence. The authors recommend further study into the efficacy and outcomes of medicines management interventions. A consensus on priority outcome measurements for prescribed medications is indicated.

TRIAL REGISTRATION

PROSPERO number CRD42017075315.

A review of interventions ≥ 6 months by pharmacists on adherence to medicines in cardiovascular disease: Characteristics of what works and what doesn't

BACKGROUND

Nonadherence to cardiovascular medicines occurs in 60% of subjects with chronic cardiovascular disease and leads to poor outcomes. In an attempt to improve adherence and cardiovascular outcomes, interventions are often used. Interventions may involve a pharmacist, but it is not always clear whether these are effective.

OBJECTIVES

The primary objective of this review is to determine whether interventions by pharmacists, alone, discussing adherence to medicines, improve adherence to medicines for cardiovascular disease. Subsequently, the review links the characteristics of the individual studies with effectiveness or lack of effect. The second objective of this review is to consider whether any improvement in adherence with interventions by pharmacist is associated with better clinical outcomes.

METHODS

A literature search of PubMed and CINAHL for 'pharmacist', 'medicine' with 'adherence' or 'compliance' or 'persistence' was undertaken. To be included in this review, papers had to be of a pharmacist working alone and in person in an intervention of subjects with hypertension, hyperlipidemia (prior to or after a coronary artery event) or heart failure. The paper had to be published in a peer review journal, with a measure of adherence to medicines. The effectiveness of the intervention had to be evaluated after ≥6 months.

RESULTS

Only 3 out of 8 interventions by pharmacists in hypertension, and 5 out of 12 interventions in subjects with hyperlipidemia led to improved adherence to medicines. In contrast, all 6 interventions by a pharmacist in subjects with heart failure were successful in improving adherence. One characteristic of successful interventions by pharmacists to improve adherence to cardiovascular medicines is that they must be more than brief/single interventions. A second characteristic is that the intervention should not involve subjects who are already highly adherent, as it is unlikely adherence can be improved in this population. Only 2 of 3 successful interventions in hypertension were associated with small reductions in blood pressure, and only one intervention in hyperlipidemia was shown to decrease LDL-cholesterol to a small extent. In subjects with heart failure, 5 of the 6 successful studies of the successful interventions by pharmacists to increase adherence also showed improved clinical outcomes.

CONCLUSIONS

When planning an intervention to improve adherence to medicines and cardiovascular outcomes in subjects with hypertension or hyperlipidemic, by a pharmacist alone, or as part of a multi-faceted interventions, it is essential to use an intervention that has been shown to be effective, as most interventions are not effective at improving adherence or only improve adherence and clinical outcomes to a small extent. In heart failure, there is well documented evidence of interventions by pharmacists that do improve clinical outcomes, which should be adopted widely.

A community-based cross-sectional survey of medication utilization among chronic disease patients in China

OBJECTIVES

To determine medication use patterns and associated health outcomes in Chinese individuals with diabetes, hypertension or hyperlipidaemia.

METHODS

This community-based cross-sectional study was done in a north China city of 300 000 people. Participants were recruited by poster and phone call through Community Health Centres. Data were collected on 638 Chinese individuals. Interviews were done to screen for disease and health behaviours. Fasting blood was collected and analyzed.

KEY FINDINGS

Participants' average age was 52 years. Self-reported prevalence of type 2 diabetes, hypertension and hyperlipidaemia was 9.6, 29.9 and 20.5% respectively. Medication adherence was found among 88, 60 and 81.5% of individuals with diabetes, hypertension and hyperlipidaemia respectively. Treatment success, as defined by medication adherence and treatment to goal was achieved by 21, 23 and 10% of diabetic, hypertensive and hyperlipidaemic patients.

CONCLUSIONS

A large proportion of individuals with chronic disease in this China-based study were not being successfully treated, putting them at high risk for poor health outcomes. In this urban China setting, healthcare services need to be strengthened in order to achieve better treatment outcomes among chronic disease patients. It is recommended that community pharmacists contribute to improving these outcomes through participation in patient education, medication reconciliation and disease state management.