1
|
Ahmed KO, Taj Eldin I, Yousif M, Albarraq AA, Yousef BA, Ahmed N, Babiker A. Clinical Pharmacist's Intervention to Improve Medication Titration for Heart Failure: First Experience from Sudan. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2021; 10:135-143. [PMID: 34796093 PMCID: PMC8593340 DOI: 10.2147/iprp.s341621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/05/2021] [Indexed: 12/28/2022] Open
Abstract
Background Medications known to improve outcomes in heart failure (HF) are either not prescribed or prescribed at sub-therapeutic doses. The addition of clinical pharmacists to the HF team positively impacts optimizing prognostic medications for a patient with HF with reduced ejection fraction (HFrEF). Objective To assess the intervention of the clinical pharmacist as part of the multidisciplinary (MD) team in up-titration to achieve target doses of key therapeutic agents for HFrEF. Methods This was a prospective one group pretest-posttest interventional study; a comparison of the target dose achievement of key therapeutic agents for HFrEF was performed before and after clinical pharmacist interventions. Results Out of 110 HFrEF patients, 57.3% were males, and the mean age of patients was 55.8 years (SD 12.6). Cardiomyopathy was the leading cause of HF. At baseline, 86% were on angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors (ACEIs/ARBs/ARNi) and 93.6% on beta blockers (BBs). At the end of study, the proportion of patients achieved the target dose was significantly increased (0 vs 77.4%, 6.8 vs 85.4%, and 0 vs 55.6%) for ACEIs, ARBs and ARNi, respectively, and (8.6% vs 66.1%; P = 0.001) for BBs. Moreover, the up-titration process was associated with significant improvement in most clinical as ejection fraction and New York Heart Association (NYHA) scale and laboratory characteristics. Conclusion As a part of the MD team in the outpatient HF clinic, the clinical pharmacists increased the percentage of HFrEF patients achieving the target or maximal doses of key therapeutic agents and improving clinical and laboratory parameters.
Collapse
Affiliation(s)
- Kannan O Ahmed
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | - Imad Taj Eldin
- Department of Pharmacology, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | - Mirghani Yousif
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Gezira, Wad Medani, Sudan
| | - Ahmed A Albarraq
- Pharmacy Practice Research Unit, Department of Clinical Pharmacy, College of Pharmacy, Jazan University, Jazan, Saudi Arabia
| | - Bashir A Yousef
- Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
| | - Nasrein Ahmed
- Department of Cardiology, Ahmed Gasim Cardiac Surgery and Renal Transplantation Centre, Khartoum, Sudan
| | - Anas Babiker
- Department of Cardiology, Royal Care International Hospital, Khartoum, Sudan
| |
Collapse
|
2
|
Arunmanakul P, Chaiyakunapruk N, Phrommintikul A, Ruengorn C, Permsuwan U. Cost-effectiveness analysis of pharmacist interventions in patients with heart failure in Thailand. J Am Pharm Assoc (2003) 2021; 62:71-78. [PMID: 34756525 DOI: 10.1016/j.japh.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/29/2021] [Accepted: 10/05/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Patients with heart failure (HF) are likely to have multiple diseases with complex therapy regimens. Pharmacist intervention in HF treatment can reduce all-cause mortality and hospitalization, but the economic outcome is not known. OBJECTIVE This study aimed to assess the cost-effectiveness of pharmacist contribution in HF setting compared with usual care. METHODS A decision analytical model was developed to estimate the cost and outcome from a health care system perspective in Thailand. Clinical inputs were obtained from literature review. Pharmacist costs, hospitalization cost for HF, risk of hospitalization death, risk of nonhospitalization death, and readmission rate were based on data from Thailand. The cost and outcome were discounted at 3% annually. OUTCOME MEASURES The incremental cost-effectiveness ratio (ICER) was calculated and presented for the year 2020. A series of sensitivity analysis was also performed. RESULTS Pharmacist intervention incurred higher total costs than usual care, because total cost of pharmacists was 186,040 THB (5936 USD) whereas usual care cost was 151,654 THB (4839 USD). It also provided more quality-adjusted life years (QALYs) than usual care, from 2.4 to 2.8. In addition, patient life years (LY) were increasing from 3.3-3.8. This yielded an ICER of 77,398 THB/LY (2467 USD/LY) or 103,037 THB/QALYs (3,288 USD/QALYs). This ICER is considered to be cost-effective at the willingness-to-pay level of 160,000 THB/QALY (5191.87 USD). CONCLUSION At this current situation in Thailand, pharmacists may represent good value for the nation's limited health care resources. The information should be used in national policies to plan for pharmacist work force implementation and production line in the near future.
Collapse
|
3
|
Dawoud DM, Haines A, Wonderling D, Ashe J, Hill J, Varia M, Dyer P, Bion J. Cost Effectiveness of Advanced Pharmacy Services Provided in the Community and Primary Care Settings: A Systematic Review. PHARMACOECONOMICS 2019; 37:1241-1260. [PMID: 31179514 DOI: 10.1007/s40273-019-00814-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
BACKGROUND Pharmacists working in community and primary care are increasingly developing advanced skills to provide enhanced services, particularly in dealing with minor acute illness. These services can potentially free-up primary care physicians' time; however, it is not clear whether they are sufficiently cost effective to be recommended for wider provision in the UK. OBJECTIVE The aim of this study was to review published economic evaluations of enhanced pharmacy services in the community and primary care settings. METHODS We undertook a systematic review of economic evaluations of enhanced pharmacy services to inform NICE guidelines for emergency and acute care. The review protocol was developed and agreed with the guideline committee. The National Health Service Economic Evaluation Database, Health Technology Assessment Database, Health Economic Evaluations Database, MEDLINE and EMBASE were searched in December 2016 and the search was updated in March 2018. Studies were assessed for applicability and methodological quality using the NICE Economic Evaluation Checklist. RESULTS Of 3124 records, 13 studies published in 14 papers were included. The studies were conducted in the UK, Spain, The Netherlands, Australia, Italy and Canada. Settings included community pharmacies, primary care/general practice surgeries and patients' homes. Most of the studies were assessed as partially applicable with potentially serious limitations. Services provided in community and primary care settings were found to be either dominant or cost effective, at a £20,000 per quality-adjusted life-year threshold, compared with usual care. Those delivered in the patient's home were not found to be cost effective. CONCLUSIONS Advanced pharmacy services appear to be cost effective when delivered in community and primary care settings, but not in domiciliary settings. Expansion in the provision of these services in community and primary care can be recommended for wider implementation.
Collapse
Affiliation(s)
- Dalia M Dawoud
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Kasr El Aini Street, Cairo, Egypt.
| | - Alexander Haines
- Toronto Health Economics and Technology Assessment Collaborative, Toronto, ON, Canada
| | - David Wonderling
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Joanna Ashe
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Jennifer Hill
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Mihir Varia
- NHS Herts Valleys Clinical Commissioning Group, Hertfordshire, UK
| | - Philip Dyer
- Diabetes, Endocrinology and Acute Internal Medicine, Diabetes Centre, University Hospitals Birmingham NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
| | - Julian Bion
- Intensive Care Medicine, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Intensive Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
4
|
Tsutsui H, Momomura SI, Masuyama T, Saito Y, Komuro I, Murohara T, Kinugawa S. Tolerability, Efficacy, and Safety of Bisoprolol vs. Carvedilol in Japanese Patients With Heart Failure and Reduced Ejection Fraction ― The CIBIS-J Trial ―. Circ J 2019; 83:1269-1277. [DOI: 10.1253/circj.cj-18-1199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | | | - Tohru Masuyama
- Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine
| | | | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Shintaro Kinugawa
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | | |
Collapse
|
5
|
Conrad N, Judge A, Canoy D, Tran J, O’Donnell J, Nazarzadeh M, Salimi-Khorshidi G, Hobbs FDR, Cleland JG, McMurray JJV, Rahimi K. Diagnostic tests, drug prescriptions, and follow-up patterns after incident heart failure: A cohort study of 93,000 UK patients. PLoS Med 2019; 16:e1002805. [PMID: 31112552 PMCID: PMC6528949 DOI: 10.1371/journal.pmed.1002805] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 04/12/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Effective management of heart failure is complex, and ensuring evidence-based practice presents a major challenge to health services worldwide. Over the past decade, the United Kingdom introduced a series of national initiatives to improve evidence-based heart failure management, including a landmark pay-for-performance scheme in primary care and a national audit in secondary care started in 2004 and 2007, respectively. Quality improvement efforts have been evaluated within individual clinical settings, but patterns of care across its continuum, although a critical component of chronic disease management, have not been studied. We have designed this study to investigate patients' trajectories of care around the time of diagnosis and their variation over time by age, sex, and socioeconomic status. METHODS AND FINDINGS For this retrospective population-based study, we used linked primary and secondary health records from a representative sample of the UK population provided by the Clinical Practice Research Datalink (CPRD). We identified 93,074 individuals newly diagnosed with heart failure between 2002 and 2014, with a mean age of 76.7 years and of which 49% were women. We examined five indicators of care: (i) diagnosis care setting (inpatient or outpatient), (ii) posthospitalisation follow-up in primary care, (iii) diagnostic investigations, (iv) prescription of essential drugs, and (v) drug treatment dose. We used Poisson and linear regression models to calculate category-specific risk ratios (RRs) or adjusted differences and 95% confidence intervals (CIs), adjusting for year of diagnosis, age, sex, region, and socioeconomic status. From 2002 to 2014, indicators of care presented diverging trends. Outpatient diagnoses and follow-up after hospital discharge in primary care declined substantially (ranging from 56% in 2002 to 36% in 2014, RR 0.64 [0.62, 0.67] and 20% to 14%, RR 0.73 [0.65, 0.82], respectively). Primary care referral for diagnostic investigations and appropriate initiation of beta blockers and angiotensin-converting-enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) both increased significantly (37% versus 82%, RR 2.24 [2.15, 2.34] and 18% versus 63%, RR 3.48 [2.72, 4.43], respectively). Yet, the average daily dose prescribed remained below guideline recommendations (42% for ACE-Is or ARBs, 29% for beta blockers in 2014) and was largely unchanged beyond the first 30 days after diagnosis. Despite increasing rates of treatment initiation, the overall dose prescribed to patients in the 12 months following diagnosis improved little over the period of study (adjusted difference for the combined dose of beta blocker and ACE-I or ARB: +6% [+2%, +10%]). Women and patients aged over 75 years presented significant gaps across all five indicators of care. Our study was limited by the available clinical information, which did not include exact left ventricular ejection fraction values, investigations performed during hospital admissions, or information about follow-up in community heart failure clinics. CONCLUSIONS Management of heart failure patients in the UK presents important shortcomings that affect screening, continuity of care, and medication titration and disproportionally impact women and older people. National reporting and incentive schemes confined to individual clinical settings have been insufficient to identify these gaps and address patients' long-term care needs.
Collapse
Affiliation(s)
- Nathalie Conrad
- The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom
- Bristol National Institute for Health Research Biomedical Research Centre, Musculoskeletal Research Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | - Dexter Canoy
- The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, United Kingdom
| | - Jenny Tran
- The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, United Kingdom
| | - Johanna O’Donnell
- The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
| | - Milad Nazarzadeh
- The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, United Kingdom
- Collaboration Center of Meta-Analysis Research, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | | | - F. D. Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, United Kingdom
| | - John G. Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow and National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - John J. V. McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Kazem Rahimi
- The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
- * E-mail:
| |
Collapse
|
6
|
DeVore AD, Schulte PJ, Mentz RJ, Hardy NC, Kelly JP, Velazquez EJ, Maya JF, Kielhorn A, Patel HK, Reed SD, Hernandez AF. Relation of Elevated Heart Rate in Patients With Heart Failure With Reduced Ejection Fraction to One-Year Outcomes and Costs. Am J Cardiol 2016; 117:946-51. [PMID: 26805662 PMCID: PMC5429586 DOI: 10.1016/j.amjcard.2015.12.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 12/16/2015] [Accepted: 12/16/2015] [Indexed: 01/06/2023]
Abstract
There are limited data describing outcomes associated with an elevated heart rate in patients with heart failure with reduced ejection fraction (HFrEF) in routine clinical practice. We identified patients with HFrEF at Duke University Hospital undergoing echocardiograms and heart rate assessments without paced rhythms or atrial fibrillation. Outcomes (all-cause mortality or hospitalization and medical costs per day alive) were assessed using electronic medical records, hospital cost accounting data, and national death records. Patients were stratified by heart rate (<70 and ≥70 beats/min) and compared using generalized linear models specified with gamma error distributions and log links for costs and proportional hazard models for mortality/hospitalization. Of 722 eligible patients, 582 patients (81%) were treated with β blockers. The median heart rate was 81 beats/min (25th and 75th percentiles 69 to 96) and 527 patients (73%) had a heart rate ≥70 beats/min. After multivariate adjustment, a heart rate ≥70 beats/min was associated with increased 1-year all-cause mortality or hospitalization, hazard ratio 1.37 (95% CI 1.07 to 1.75) and increased medical costs per day alive, cost ratio 2.03 (95% CI 1.53 to 2.69). In conclusion, at a large tertiary care center, despite broad use of β blockers, a heart rate ≥70 beats/min was observed in 73% of patients with HFrEF and associated with worse 1-year outcomes and increased direct medical costs per day alive.
Collapse
Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
| | - Phillip J Schulte
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Jacob P Kelly
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Eric J Velazquez
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Juan F Maya
- Amgen Incorporated, Thousand Oaks, California
| | | | | | - Shelby D Reed
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
7
|
Kang JE, Han NY, Oh JM, Jin HK, Kim HA, Son IJ, Rhie SJ. Pharmacist-involved care for patients with heart failure and acute coronary syndrome: a systematic review with qualitative and quantitative meta-analysis. J Clin Pharm Ther 2016; 41:145-57. [DOI: 10.1111/jcpt.12367] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 02/01/2016] [Indexed: 11/27/2022]
Affiliation(s)
- J. E. Kang
- Division of Life and Pharmaceutical Sciences Graduate School and College of Pharmacy; Ewha Womans University; Seoul Korea
- Department of Pharmacy; National Medical Center; Seoul Korea
| | - N. Y. Han
- College of Pharmacy; Seoul National University; Seoul Korea
| | - J. M. Oh
- College of Pharmacy; Seoul National University; Seoul Korea
| | - H. K. Jin
- Division of Life and Pharmaceutical Sciences Graduate School and College of Pharmacy; Ewha Womans University; Seoul Korea
| | - H. A. Kim
- Division of Life and Pharmaceutical Sciences Graduate School and College of Pharmacy; Ewha Womans University; Seoul Korea
| | - I. J. Son
- Department of Pharmacy; National Medical Center; Seoul Korea
| | - S. J. Rhie
- Division of Life and Pharmaceutical Sciences Graduate School and College of Pharmacy; Ewha Womans University; Seoul Korea
| |
Collapse
|
8
|
Kul S, Vanhaecht K, Panella M. Intraclass correlation coefficients for cluster randomized trials in care pathways and usual care: hospital treatment for heart failure. BMC Health Serv Res 2014; 14:84. [PMID: 24565441 PMCID: PMC3974056 DOI: 10.1186/1472-6963-14-84] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 02/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cluster randomized trials are increasingly being used in healthcare evaluation to show the effectiveness of a specific intervention. Care pathways (CPs) are becoming a popular tool to improve the quality of health-care services provided to heart failure patients. In order to perform a well-designed cluster randomized trial to demonstrate the effectiveness of Usual care (UC) and CP in heart failure treatment, the intraclass correlation coefficient (ICC) should be available before conducting a trial to estimate the required sample size. This study reports ICCs for both demographical and outcome variables from cluster randomized trials of heart failure patients in UC and care pathways. METHODS To calculate the degree of within-cluster dependence, the ICC and associated 95% confidence interval were calculated by a method based on analysis of variance. All analyses were performed in R software version 2.15.1. RESULTS ICCs for baseline characteristics ranged from 0.025 to 0.058. The median value and interquartile range was 0.043 [0.026-0.052] for ICCs of baseline characteristics. Among baseline characteristics, the highest ICCs were found for admission by referral or admission from home (ICC = 0.058) and the disease severity at admission (ICC = 0.046). Corresponding ICCs for appropriateness of the stay, length of stay and hospitalization cost were 0.069, 0.063, and 0.001 in CP group and 0.203, 0.020, 0.046 for usual care, respectively. CONCLUSION Reported values of ICCs from present care pathway trial and UC results for some common outcomes will be helpful for estimating sample size in future clustered randomized heart failure trials, in particular for the evaluation of care pathways.
Collapse
Affiliation(s)
- Seval Kul
- Department of Biostatistics, Faculty of Medicine, University of Gaziantep, Gaziantep, Turkey
| | - Kris Vanhaecht
- Department of Public Health and Primary Care, KULeuven, University of Leuven, and University Hospitals Leuven, Leuven, Belgium
- Western Norway Network on Integrated Care, Helse Fonna, Haugesund, Norway
- European Pathway Association, Leuven, Belgium
| | - Massimiliano Panella
- European Pathway Association, Leuven, Belgium
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont 'A. Avogadro', Novara, Italy
| |
Collapse
|
9
|
Swedberg K, Komajda M, Böhm M, Borer J, Robertson M, Tavazzi L, Ford I. Effects on Outcomes of Heart Rate Reduction by Ivabradine in Patients With Congestive Heart Failure: Is There an Influence of Beta-Blocker Dose? J Am Coll Cardiol 2012; 59:1938-45. [DOI: 10.1016/j.jacc.2012.01.020] [Citation(s) in RCA: 189] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 12/30/2011] [Accepted: 01/03/2012] [Indexed: 11/17/2022]
|
10
|
Lowrie R, Mair FS, Greenlaw N, Forsyth P, Jhund PS, McConnachie A, Rae B, McMurray JJ. Pharmacist intervention in primary care to improve outcomes in patients with left ventricular systolic dysfunction. Eur Heart J 2011; 33:314-24. [DOI: 10.1093/eurheartj/ehr433] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|