Integration of clinical pharmacists into a heart failure clinic within a safety-net hospital

Abstract

Background: Management of heart failure with reduced ejection fraction (HFrEF) requires timely initiation and up-titration of guideline-directed medical therapy (GDMT). In safety-net hospitals (SNHs), limited health care staff and resources make achievement of optimal medical therapy challenging. Recent studies have shown that medication titration performed by clinical pharmacists can improve outcomes in ambulatory management of HFrEF; however, the impact of these services within an SNH remains unknown. Objective: Determine the impact of integrating clinical pharmacists into a heart failure (HF) clinic on initiation and titration of GDMT within an SNH. Methods: We performed a single-center retrospective cohort study of patients with HFrEF treated in an ambulatory HF medication titration clinic within an SNH before and after clinical pharmacist integration. Primary outcomes included dose optimization rates of GDMT, time between clinic visits, and time to optimization of GDMT. Exploratory secondary outcomes were all-cause, HF, and cardiovascular acute care service utilization and all-cause, HF, and cardiovascular mortality before and after clinical pharmacist integration up to 6 months after initial clinic visit. Results: A total of 153 patients with HFrEF were treated. Baseline characteristics in the preand postintervention groups were comparable. After clinical pharmacist integration, there was a statistically significant improvement in optimization of renin-angiotensin-aldosterone system inhibitor or hydralazine-nitrate equivalent (82% vs. 94%, P ¼ 0.02). Dose optimization rates of beta-blockers (90% vs. 83%, P ¼ 0.22) and mineralocorticoid receptor antagonists (57% vs. 57%, P > 0.99) were unchanged. There was a statistically significant reduction in mean time between clinic visits (26 vs. 14 days, P < 0.001) and in mean time to optimization of GDMT (88 vs. 45 days, P ¼ 0.002). All-cause mortality was reduced (13% vs. 2%, P ¼ 0.01). Conclusion:In SNHs, where limited health care staff and resources present as barriers to timely initiation and titration of GDMT, integration of clinical pharmacists into HF clinics can serve as a practical solution.

Effects of clinical interventions through a comprehensive medication management program: A retrospective study among outpatients in a private hospital

“…This attests to the substantial advantages of enhancing the network of care for polypharmacy patients. 6 , 15 , 16 , 17 …”

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

“…Early management of CTRCD with CV drug optimization during follow-up is associated with LVEF recovery ( 23 , 24 ). Clinical pharmacists have an essential role at the HF clinic in the initiation and titration of guideline-directed medical therapy collaboratively with the HF team, decreasing the risk of re-hospitalization and reducing all-cause mortality by 13% ( 25 – 27 ).…”

Integration of implantable device therapy in patients with heart failure. A clinical consensus statement from the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC)

“…Some healthcare systems allow for pharmacist-led HF clinics that provide opportunities to screen for device eligibility, optimize medical therapies and provide patient information. 147 Cardiac device technicians can have an important role in device optimization including recognizing patients who require escalation of care. HF nurses, allied professionals and healthcare scientists involved in the management of HF should have the appropriate level of training and competence to improve patient care and appropriate access to HF therapies.…”

“…In addition, allied professionals and healthcare scientists can have an important role as part of the HF multidisciplinary team, although these professions currently only exist in a small number of European countries. Some healthcare systems allow for pharmacist‐led HF clinics that provide opportunities to screen for device eligibility, optimize medical therapies and provide patient information 147 . Cardiac device technicians can have an important role in device optimization including recognizing patients who require escalation of care.…”