Defining pharmacist activities in ambulatory heart failure clinics: North American survey and modified Delphi study

Abstract

BackgroundPharmacists are key members of multidisciplinary heart failure (HF) clinics; however, there is variation in their roles and activities. This study aimed to: (1) define current roles of HF clinic pharmacists and (2) develop a consensus‐based list of key activities for HF clinic pharmacists.MethodsIn part 1, we invited Canadian and American HF clinic pharmacists to complete a survey on activities currently performed in the HF clinic. Part 2 consisted of a three‐round modified Delphi study including only Canadian participants to define key activities for ambulatory HF pharmacists among 44 candidates. In each round, participants rated a list of candidate activities based on importance and priority on a 9‐point Likert scale. Consensus was reached for inclusion when ≥75% of participants rated both criteria ≥7, or exclusion when both criteria ≤6. Participants received personal responses alongside aggregate ratings after each round to facilitate attainment of consensus.ResultsEighty‐four pharmacists participated in part 1, and 29 (of 55 invited) participated in part 2 (24 retained for all three rounds). Current pharmacist activities were similar between American and Canadian participants, with an emphasis on patient assessment and clinical activities including modification of HF‐specific pharmacotherapy. The final consensus‐based list included 32 activities, with high priority placed on activities involving optimization of medications for HF and common comorbidities, engaging in shared decision‐making, assessing adherence, reviewing lab tests, and assessing and modifying medications due to pharmacokinetic/pharmacodynamic parameters, which closely mirrored activities in current practice.ConclusionCurrent activities of ambulatory HF pharmacists are largely consistent within North America, focusing on patient assessment and HF‐specific pharmacotherapy modification. Our consensus‐based list defined 32 activities integral to the future role of pharmacists in HF clinics, which builds upon activities being currently performed. This provides a framework to standardize and expand the scope of practice for clinical pharmacy services in HF clinics.

Evaluation of PHARM‐HF, a pharmacist‐led heart failure medication titration clinic: A pre‐post study

“…Early observational studies of pharmacist‐led HFrEF medication titration approaches have found an increase in GDMT therapy uptake and associated improvements in patient outcomes 8 . In North America, pharmacists have an increasing presence in HF medication management, although their specific roles and delegated activities vary 18 . However, consensus among pharmacists specializing in HF care has recently emerged such that their role should focus on “hands‐on” pharmacotherapy assessment and management including medication initiation and titration, modification of pharmacotherapy for comorbid conditions (e.g., atrial fibrillation and diabetes), and medication adjustment based on adverse drug events 18 .…”

“…In North America, pharmacists have an increasing presence in HF medication management, although their specific roles and delegated activities vary 18 . However, consensus among pharmacists specializing in HF care has recently emerged such that their role should focus on “hands‐on” pharmacotherapy assessment and management including medication initiation and titration, modification of pharmacotherapy for comorbid conditions (e.g., atrial fibrillation and diabetes), and medication adjustment based on adverse drug events 18 . In the present study, we show that pharmacists who are empowered by their team and institution to do this work can successfully implement such medication management activities.…”

“…Although many sites in Canada and the United States have successfully incorporated pharmacist‐led HFrEF medication optimization services, this remains far from the standard of care, and many HF clinics are under‐resourced in terms of even basic clinical pharmacy services 18 . There is a need for definitive evidence from a large‐scale randomized controlled trial to demonstrate the value of pharmacist‐led HF medication optimization to enable decision‐makers, including health system leaders, payers, and policymakers to make strong recommendations regarding allocation of resources toward HF‐specific clinical pharmacy services and incorporating this approach as standard of care for patients with HFrEF.…”