Effectiveness of visits from community pharmacists for patients with heart failure: HeartMed randomised controlled trial

Impact of pharmacist-led pharmaceutical care on health-related and pharmaceutical therapy-related quality of life in patients with heart failure: A randomized controlled trial

BACKGROUND

Data on the impact of pharmacist-led pharmaceutical care (PC) on pharmaceutical therapy-related and health-related quality of life (HRQoL) and their sensitivities to PC provision in patients with heart failure (HF) are scarce.

OBJECTIVES

This study aimed to assess the impact of pharmacist-led PC on HRQoL employing the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and 5-level EuroQol 5 dimension (EQ-5D-5L) and on pharmaceutical therapy-related quality of life using the Patient-Reported Outcomes Measure of Pharmaceutical Therapy (PROMPT) in HF patients and compare sensitivities to the PC provision of these three tools.

METHODS

A single-blinded randomized controlled trial was conducted at a tertiary public hospital in Thailand between November 2022 and May 2023. Overall, 250 patients were randomly divided into the usual care (UC) (N = 124) and PC (N = 126) groups. Mixed effects models were used to investigate the differences in the mean change scores of PROMPT, EQ-5D-5L, and MLHFQ between the UC and PC groups. The sensitivities to PC provision of the three measures were evaluated using standardized effect sizes (SESs).

RESULTS

Significant differences were found in five of eight domains and the total score of the PROMPT between the PC and UC groups (all p < 0.05). However, no significant differences were found in the EQ-5D-5L and MLHFQ between the two groups (both p > 0.05). The SESs of the five domains and total score of PROMPT ranged from 0.29 to 1.65, considered small-to-large effect sizes, whereas the SESs of EQ-5D-5L and MLHFQ were -0.4 to 0, considered small effect sizes.

CONCLUSIONS

Pharmacist-led PC can positively affect pharmaceutical therapy-related quality of life using PROMPT in HF patients. Additionally, PROMPT is more sensitive to PC provision than EQ-5D-5L and MLHFQ.

Research Gaps in Pediatric Heart Failure: Defining the Gaps and Then Closing Them Over the Next Decade

Given the numerous opportunities and the wide knowledge gaps in pediatric heart failure, an international group of pediatric heart failure experts with diverse backgrounds were invited and tasked with identifying research gaps in each pediatric heart failure domain that scientists and funding agencies need to focus on over the next decade.

Association of pharmacist intervention counseling with medication adherence and quality of life: A systematic review and meta-analysis of randomized trials

OBJECTIVE(S)

To assess the association between pharmacist intervention counseling with medication adherence and quality of life. Also, to assess if these associations vary by the focus, structure, training, or robustness of the counseling.

METHODS

The initial search identified 1805 references, of which 62 randomized trials (RCTs) met inclusion criteria for the systematic review. Of the 62 RCTs, 60 (with 62 results) had extractable data for the meta-analysis. Data were pooled using a random-effects model.

RESULTS

Most study patients were older and taking multiple prescription drugs. The pooled results showed a statistically significant increase in the odds of medication adherence with the pharmacist counseling intervention versus no counseling (pooled odds ratio [OR] = 4.41; 95% confidence interval [CI] 2.46-7.91; P < 0.01). The results of a subgroup analysis suggest the primary disease, counseling focus, location, and robustness may modify the effect of pharmacist counseling on medication adherence. There was a statistically significant improvement in the quality of life with pharmacist counseling versus no pharmacist counseling (pooled standardized mean difference [SMD] = 0.69; 95% CI 0.41-0.96; P < 0.01). The results of a subgroup analysis suggest that counseling focus, location, training, robustness, and the measurement method, but not the disease category, may modify the effect of pharmacist counseling on quality of life.

CONCLUSION

The evidence supports pharmacist intervention counseling to increase mediation adherence and quality of life. The counseling location and structure may be significant factors in improving medication adherence. The overall methodological quality of evidence was very low.

Elements Characterising Multicomponent Interventions Used to Improve Disease Management Models and Clinical Pathways in Acute and Chronic Heart Failure: A Scoping Review

This study aimed to summarise different interventions used to improve clinical models and pathways in the management of chronic and acute heart failure (HF). A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. MEDLINE (via PubMed), Embase, The Cochrane Library, and CINAHL were searched for systematic reviews (SR) published in the period from 2014 to 2019 in the English language. Primary articles cited in SR that fulfil inclusion and exclusion criteria were extracted and examined using narrative synthesis. Interventions were classified based on five chosen elements of the Chronic Care Model (CCM) framework (self-management support, decision support, community resources and policies, delivery system, and clinical information system). Out of 155 SRs retrieved, 7 were considered for the extraction of 166 primary articles. The prevailing setting was the patient's home. Only 46 studies specified the severity of HF by reporting the level of left ventricular ejection fraction (LVEF) impairment in a heterogeneous manner. However, most studies targeted the populations with LVEF ≤ 45% and LVEF < 40%. Self-management and delivery systems were the most evaluated CCM elements. Interventions related to community resources and policy and advising/reminding systems for providers were rarely evaluated. No studies addressed the implementation of a disease registry. A multidisciplinary team was available with similarly low frequency in each setting. Although HF care should be a multi-component model, most studies did not analyse the role of some important components, such as the decision support tools to disseminate guidelines and program planning that includes measurable targets.

Multidimensional Interventions on Supporting Disease Management for Hospitalized Patients with Heart Failure: The Role of Clinical and Community Pharmacists

BACKGROUND

existing trials on the role of clinical pharmacists in managing chronic disease patients have focused on variety of interventions, including preparing patients for the transition from hospital to home. However, little quantitative evidence is available regarding the effect of multidimensional interventions on supporting disease management for hospitalized patients with heart failure (HF). The present paper reviews the effects of inpatient, discharge and/or after-discharge interventions performed on hospitalized HF patients by multidisciplinary teams, including pharmacists.

METHODS

articles were identified through search engines in three electronic databases following the PRISMA Protocol. Randomized controlled trials (RCTs) or non-randomized intervention studies conducted in the period 1992-2022 were included. In all studies, baseline characteristics of patients as well as study end-points were described in relation to a control group i.e., usual care and a group of subjects that received care from a clinical and/or community pharmacist, as well as other health professionals (Intervention). Study outcomes included all-cause hospital 30-day re-admission or emergency room (ER) visits, all-cause hospitalization within >30 days after discharge, specific-cause hospitalization rates, medication adherence and mortality. The secondary outcomes included adverse events and quality of life. Quality assessment was carried out using RoB 2 Risk of Bias Tool. Publication bias across studies was determined using the funnel plot and Egger's regression test.

RESULTS

a total of 34 protocols were included in the review, while the data from 33 trials were included in further quantitative analyses. The heterogeneity between studies was high. Pharmacist-led interventions, usually performed within interprofessional care teams, reduced the rates of 30-day all-cause hospital re-admission (odds ratio, OR = 0.78; 95% CI 0.62-0.98; p = 0.03) and all-cause hospitalization >30 days after discharge (OR = 0.73; 95% CI 0.63-0.86; p = 0.0001). Subjects hospitalized primarily due to heart failure demonstrated reduced risk of hospital admission within longer periods, i.e., from 60 to 365 days after discharge (OR = 0.64; 95% CI 0.51-0.81; p = 0.0002). The rate of all-cause hospitalization was reduced by multidimensional interventions taken by pharmacists: reviews of medicine lists and/or their reconciliation at discharge (OR = 0.63; 95% CI 0.43-0.91; p = 0.014), as well as interventions that were based mainly on patient education and counseling (OR = 0.65; 95% CI 0.49-0.88; p = 0.0047). In conclusion, given that HF patients often have complex treatment regimens and multiple comorbid conditions, our findings highlight the need for greater involvement from skilled clinical and community pharmacists in disease management.

Haefeli W, M. Seidling H. Mortality and Hospitalizations Among Patients Enrolled in an Interprofessional Medication Management Program

BACKGROUND

Measures for improving medication safety in outpatient care are often complex and involve medication reviews. Over the period 2016-2022 (with a preceeding one-year pilot phase), an interprofessional medication management program- the Medicines Initiative Saxony-Thuringia (Arzneimittelinitiative Sachsen-Thüringen, ARMIN)-was implemented in two German federal states. More than 5000 patients received a medication review by the end of 2019 by a team composed of physicians and pharmacists and were provided with joint, continuous care thereafter.

METHODS

In the framework of a retrospectively registered cohort study, the mortality and hospitalizations of this population (5033 patients) were studied using routine data from a statutory health insurer (observation period 2015-2019) and compared with those of a control group (10 039 patients) determined from the routine data by propensity score matching. Mortality was compared by survival analysis (Cox regression), and hospitalization rates were compared in terms of event probabilities within two years of enrollment in the medication management program. Robustness was tested in multiple sensitivity analyses.

RESULTS

Over the observation period, 9.3% of the ARMIN participants and 12.9% of persons in the control group died (hazard ratio of the adjusted Cox regression, 0.84; 95% confidence interval [0.76; 0.94], P = 0.001). In the first two years after inclusion, the ARMIN participants were hospitalized just as often as the persons in the control group (52.4% versus 53.4%; odds ratio from the adjusted model, 1.04 [0.96; 1.11], P = 0.347). The effects were consistent in sensitivity analyses.

CONCLUSION

In this retrospective cohort study, participation in the ARMIN program was associated with a lower risk of death. Exploratory analyses provide clues to the potential origin of this association.

The Impact of Pharmacist-Led Medication Management Services on the Quality of Life and Adverse Drug Reaction Occurrence

The aim of this research was to assess the impact of comprehensive medication management (CMM) services on patients’ health-related quality of life (HRQoL) and frequency of adverse drug reactions (ADRs) in older patients with cardiovascular diseases (CVDs). A prospective, pre- and post-intervention study with a one-year follow-up was conducted at the Health Care Centre Zagreb—Centre (HCZC). The Euro-Quality of Life Questionnaire 5 Dimensions 5 Levels (EQ-5D-5L) was used to measure the HRQoL at baseline (initial visit at the HCZC) and 12 months following CMM services. The ADRs collected at the initial assessment of the CMM services and throughout follow-up consultations were analyzed according to the occurrence mechanism, seriousness, expectedness and distribution of the Preferred Term according to the System Organ Class. Following the CMM intervention, 65 patients reported significant improvement in dimensions “self-care” (p = 0.011) and “usual activities” (p = 0.003), whereas no significant change was found in the “mobility” (p = 0.203), “pain/discomfort” (p = 0.173) and “anxiety/depression” (p = 0.083) dimensions and the self-rated VAS scale (p = 0.781). A total of 596 suspected ADR reports were found, the majority at patients’ initial assessment (67.3%), with a mean ± SD of 9.2 ± 16.9 per patient. The CMM services significantly reduced the rate of suspected ADRs, namely 2.7 ± 1.7 ADRs per patient at the initial assessment vs. 1.0 ± 1.5 ADRs per patient at the last consultation (p < 0.001). The obtained results indicate that CMM services may improve patients’ HRQoL. Additionally, as CMM services diminished the proportion of ADRs following 1-year patient follow-up, they may serve as a viable solution for safety management.

Contextualising evidence based medicine in determining the key root for translational effectiveness for chronic disease self-management and heart failure

BACKGROUND

Congestive heart failure (CHF) management has proven devastating on morbidity, mortality, quality of life and also costly to health systems. Therapeutics for CHF have advanced and benefited greatly due to large multicentre randomised controlled trials and the evidence obtained from them. Management for chronic diseases and nonpharmaceutical therapies such as chronic disease self-management has lagged, and for CHF the evidence base has even been questioned.

METHODS

Perspective and non systematic mini review.

CONCLUSIONS

Advancing translational research standards is important to achieve optimal cost effectiveness. Importantly is understanding evidence generation in medicine, identifying the primary roots for management and its translation.

Impact of pharmacist-led interventions on patient care in ambulatory care settings: A systematic review

BACKGROUND

In an era of rapid evolution in healthcare delivery, major changes have occurred within the profession of pharmacist. Because the impact of pharmacist-led interventions in the hospital setting has been well-studied and showed mixed findings on drug-related readmissions, all-cause emergency department visits and mortality, this systematic review focused on services provided by pharmacists in the community or ambulatory care setting without being limited to a specific intervention or outcome.

OBJECTIVE

To investigate the impact of pharmacist-led interventions, categorised into clinical medication review (CMR), adherence review (AR), and prescription review (PR) on various aspects of patient care (clinical, behavioural, economic and humanistic outcomes in ambulatory care setting) and understand which particular intervention makes the greatest contribution.

METHODS

A literature search was conducted using MEDLINE, Embase and the Cochrane Library for publications from 2000 onwards.

FINDINGS AND INTERPRETATION

A total of 31 relevant publications corresponding to 27 controlled trials (CTs) and 4 observational studies were selected. CMR was the most studied pharmacist-led intervention (n = 19, 61.29%), followed by AR (n = 6, 19.3%). CMR demonstrated a favourable effect on different clinical outcomes mainly the management of drug-related problems and adverse events, and it also contributed the most to the reduction of healthcare costs. AR was the most effective intervention to improve patient's adherence. CMR alone or combined with AR both raised equally the patient's satisfaction.

CONCLUSION

Our results showed that CMR can play a major role in the management of drug-related problems and economic issues. AR can significantly improve patient compliance. Larger, standardised and rigorously designed intervention studies are needed to help decision-makers to select appropriate interventions leading to meaningful improvements in patient care.

Cost-effectiveness analysis of pharmacist interventions in patients with heart failure in Thailand

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.

Effectiveness of Pharmacist Intervention to Reduce Medication Errors and Health-Care Resources Utilization After Transitions of Care: A Meta-analysis of Randomized Controlled Trials

OBJECTIVES

Medication errors are common during transitions of care. The main objective of the current investigation was to examine the effectiveness of pharmacist-based transition of care interventions on the reduction of medication errors after hospital discharge.

METHODS

A systematic search was conducted to detect published reports of randomized trials using the National Library of Medicine's PubMed database, the Cochrane Database of Systematic Reviews, and Google Scholar inclusive to July 1, 2015. Search terms included pharmacist, medication, errors, readmission, transition, and discharge. A priori main outcomes included medication errors and health-care resources utilization (hospital readmission and/or emergency room visits). Quantitative analysis was performed using a random effect method.

RESULTS

Thirteen randomized trials examining 3503 patients were included in the final analysis. The aggregate effect of the 10 studies evaluating the effect of pharmacists intervention on the incidence of medication errors during transitions of care favored pharmacist over control with an odds ratio (95% confidence interval [CI]) of 0.44 (0.31-0.63). The overall effect of 4 studies evaluating the effect of a pharmacist intervention on the incidence of emergency room visits compared with control favored the pharmacist intervention, odds ratio (95% CI) of 0.42 (0.22-0.78), number needed to treat (95% CI) of 6.2 (3.4-31.4).

CONCLUSIONS

Pharmacist transition of care intervention is an effective strategy to reduce medication errors after hospital discharge. In addition, a pharmacist intervention also reduces subsequent emergency room visits. Hospitals should consider implementing this intervention to improve patient safety and quality during transitions of care.

Impact of pharmacist and physician collaborations in primary care on reducing readmission to hospital: A systematic review and meta-analysis

BACKGROUND

Readmissions to hospital due to medication-related problems are common and may be preventable. Pharmacists act to optimise use of medicines during care transitions from hospital to community.

OBJECTIVE

To assess the impact of pharmacist-led interventions, which include communication with a primary care physician (PCP) on reducing hospital readmissions.

METHODS

PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL and Web of Science were searched for articles published from inception to March 2021 that described interventions involving a pharmacist interacting with a PCP in regards to medication management of patients recently discharged from hospital. The primary outcome was effect on all-cause readmission expressed as Mantel-Haenszel risk ratio (RR) derived from applying a random effects model to pooled data. Sensitivity analysis was also conducted to investigate differences between randomised controlled trials (RCTs) and non-RCTs. The GRADE system was applied in rating the quality of evidence and certainty in the estimates of effect.

RESULTS

In total, 37 studies were included (16 RCTs and 29 non-RCTs). Compared to control patients, the proportion of intervention patients readmitted at least once was significantly reduced by 13% (RR = 0.87, CI:0.79-0.97, p = 0.01; low to very low certainty of evidence) over follow-up periods of variable duration in all studies combined, and by 22% (RR = 0.78, CI:0.67-0.92; low certainty of evidence) at 30 day follow-up across studies reporting this time point. Analysis of data from RCTs only showed no significant reduction in readmissions (RR = 0.92, CI:0.80-1.06; low certainty of evidence).

CONCLUSIONS

The totality of evidence suggests pharmacist-led interventions with PCP communication are effective in reducing readmissions, especially at 30 days follow-up. Future studies need to adopt more rigorous study designs and apply well-defined patient eligibility criteria.

The evidence for pharmacist care in outpatients with heart failure: a systematic review and meta-analysis

Aims

Patients with heart failure (HF) have poor outcomes, including poor quality of life, and high morbidity and mortality. In addition, they have a high medication burden due to the multiple drug therapies now recommended by guidelines. Previous reviews, including studies in hospital settings, provided evidence that pharmacist care improves outcomes in patients with HF. Because most HF is managed outside of hospitals, we aimed to synthesize the evidence for pharmacist care in outpatients with HF.

Methods and results

We conducted a systematic literature search in PubMed of randomized controlled trials (RCTs) and integrated the evidence on patient outcomes in a meta‐analysis. We found 24 RCTs performed in 10 countries, including 8029 patients. The data revealed consistent improvements in medication adherence (independent of the measuring instrument) and knowledge, physical function, and disease and medication management. Sixteen RCTs were included in meta‐analyses. Differences in all‐cause mortality (odds ratio (OR) = 0.97 [95% CI, 0.84–1.12], Q‐statistic, P = 0.49, I² = 0%), all‐cause hospitalizations (OR = 0.86 [0.73–1.03], Q‐statistic, P = 0.01, I² = 45.5%), and HF hospitalizations (OR = 0.89 [0.77–1.02], Q‐statistic, P = 0.11, I² = 0%) were not statistically significant. We also observed an improvement in the standardized mean difference for generic quality of life of 0.75 ([0.49–1.01], P < 0.01), with no indication of heterogeneity (Q‐statistic, P = 0.64; I² = 0%).

Conclusions

Results indicate that pharmacist care improves medication adherence and knowledge, symptom control, and some measures of quality of life in outpatients with HF. Given the increasing complexity of guideline‐directed medical therapy, pharmacists' unique focus on medication management, titration, adherence, and patient teaching should be considered part of the management strategy for these vulnerable patients.

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.

Effect of Educational Interventions to Reduce Readmissions due to Heart Failure Decompensation in Adults: a Systematic Review and Meta-analysis

OBJECTIVES

To estimate the combined effect of educational interventions (EI) on decreased readmissions and time of hospital stay in adults with heart failure, compared with usual care.

METHODS

Systematic review (SR) and meta-analysis (MA) of randomized controlled trials that followed the recommendations of the PRISMA statement. The protocol was registered on PROSPERO (CRD42019139321). Searches were made from inception until July 2019 in the databases of PubMed/Medline, Embase, Cochrane CENTRAL, Lilacs, Web of Science, and Scopus. The MA was conducted through the random effects model. The effect measure used for the dichotomous outcomes was relative risk (RR) and for continuous outcomes the mean difference (MD) was used, with 95% confidence intervals (CI). Heterogeneity was evaluated through the inconsistency statistic (I2).

RESULTS

Of 2369 studies identified, 45 were included in the SR and 43 in the MA. The MA of studies with follow-up at six months showed a decrease in readmissions of 30% (RR: 0.70; 95% CI: 0.58 to 0.84; I2: 0%) and the 12-month follow-up evidenced a reduction of 33% (RR: 0.67; 95% CI: 0.58 to 0.76; I2: 52%); both analyses in favor of the EI group. Regarding the time of hospital stay, a reduction was found of approximately two days in patients who received the EI (MD: -1.98; 95% CI: -3.27 to -0.69; I2: 7%).

CONCLUSIONS

The findings support the benefits of EI to reduce readmissions and days of hospital stay in adult patients with heart failure.

Symptom perception in heart failure - Interventions and outcomes: A scoping review

BACKGROUND

Symptom perception in heart failure has recently been described as essential in the self-care process bridging self-care maintenance and self-care management. Accordingly, symptom perception appears to be critical for improving patient outcomes such as decreased hospital readmission and increased survival.

OBJECTIVES

To explore what interventions have been reported on heart failure symptom perception and to describe outcomes responsive to symptom perception.

DESIGN

We conducted a scoping review using PRISMA Extension for Scoping Reviews.

DATA SOURCES

Structured searches of Medline, PubMed, Embase, CINAHL, PsychINFO, Web of Science, Cochrane, Joanna Briggs Institute and Grey literature databases.

REVIEW METHODS

Two authors independently screened references for eligibility. Eligible articles were written in English, French, German, Swedish, Italian or Spanish and concerned symptom perception in adults with heart failure. Data were extracted and charted in tables by three reviewers. Results were narratively summarized.

RESULTS

We identified 99 eligible studies from 3055 references. Seven interventional studies targeted symptom perception as the single intervention component. Mixed results have been found: while some reported decreased symptom frequency, intensity and distress, enhanced health-related quality of life, improved heart failure self-care maintenance and management as well as a greater ability to mention heart failure symptoms, others found more contacts with healthcare providers or no impact on anxiety, heart failure self-care nor a number of diary reported symptoms. Additional interventional studies included symptom perception as one component of a multi-faceted intervention. Outcomes responsive to symptom perception were improved general and physical health, decreased mortality, heart failure decompensation, as hospital/emergency visits, shorter delays in seeking care, more consistent weight monitoring, improved symptom recognition as well as self-care management, decreased hospital length of stay and decreased costs.

CONCLUSIONS

While many studies allowed to map a comprehensive overview of interventions supporting symptom perception in heart failure as well as responsiveness to outcomes, only a few single component intervention studies targeting symptom perception have been reported and study designs preclude assessing intervention effectiveness. With regard to multiple component interventions, the specific impact of symptom perception interventions on outcomes remains uncertain to date. Well-designed studies are needed to test the effectiveness of symptom perception interventions and to elucidate relationships with outcomes.

The effectiveness of transitional care interventions for adult people with heart failure on patient-centered health outcomes: A systematic review and meta-analysis including dose-response relationship

BACKGROUND

Transitional care interventions that bridge the care gap from hospital to home have proven to be effective in lessening the burden of healthcare systems by reducing hospital readmissions. Yet, the effects of transitional care interventions on patient-centered health outcomes of mortality, quality of life, and emotional distress remains unclear.

OBJECTIVES

To evaluate the effectiveness and dose-response of transitional care interventions on patient-centered health outcomes of mortality, quality of life, and emotional distress among individuals with heart failure and to identify the trial-level characteristics potentially affecting the overall effectiveness.

DESIGN

Systematic review with random-effects meta-analysis, meta-regression, and dose-response analysis of randomized controlled trials comparing transitional care interventions with usual care in adult people hospitalized with heart failure.

DATA SOURCES

Electronic databases including MEDLINE, Embase, Cochrane Library, and CINAHL were systematically searched from January 1, 2000 to June 31, 2020.

REVIEW METHODS

Authors independently reviewed the retrieved articles based on inclusion and exclusion criteria, extracted data, and assessed risk of bias using the Cochrane risk-of-bias tool version 2.0. We pooled data from each study using random-effects meta-analysis and performed meta-regression to explore the impact of pre-specified trial-level factors. Dose-response meta-analysis was conducted to examine the relationship between the intensity (i.e., frequency and duration of interventions) and complexity (i.e., number of intervention components) of transitional care interventions and the treatment effects.

RESULTS

Data were synthesized from 42 trials covering a total of 10,784 people with heart failure. Comparing to usual care, transitional care interventions achieved pooled evidence of a mean 18% risk reduction on mortality (0.82, 95% CI 0.71 to 0.95, P = 0.009) and better improvement in quality of life (-4.37, 95% CI -7.20 to -1.54, P = 0.002). There were insufficient data to determine with certainty the effects on anxiety and depression. Meta-regression showed greater efficacy in trials that delivered the intervention by a multidisciplinary team. Dose-response analyses demonstrated that mortality and quality of life were improved with increased intensity and complexity of the transitional care interventions.

CONCLUSIONS

Transitional care interventions were effective in reducing mortality and improving quality of life for adult people with heart failure. The effects on emotional distress were inconclusive due to insufficient data, highlighting the need for further research.

REGISTRATION NUMBER

CRD42019132732.

Health State Utilities of Patients with Heart Failure: A Systematic Literature Review

BACKGROUND AND OBJECTIVES

New treatments and interventions are in development to address clinical needs in heart failure. To support decision making on reimbursement, cost-effectiveness analyses are frequently required. A systematic literature review was conducted to identify and summarize heart failure utility values for use in economic evaluations.

METHODS

Databases were searched for articles published until June 2019 that reported health utility values for patients with heart failure. Publications were reviewed with specific attention to study design; reported values were categorized according to the health states, 'chronic heart failure', 'hospitalized', and 'other acute heart failure'. Interquartile limits (25th percentile 'Q1', 75th percentile 'Q3') were calculated for health states and heart failure subgroups where there were sufficient data.

RESULTS

The systematic literature review identified 161 publications based on data from 142 studies. Utility values for chronic heart failure were reported by 128 publications; 39 publications published values for hospitalized and three for other acute heart failure. There was substantial heterogeneity in the specifics of the study populations, methods of elicitation, and summary statistics, which is reflected in the wide range of utility values reported. EQ-5D was the most used instrument; the interquartile limit for mean EQ-5D values for chronic heart failure was 0.64-0.72.

CONCLUSIONS

There is a wealth of published utility values for heart failure to support economic evaluations. Data are heterogenous owing to specificities of the study population and methodology of utility value elicitation and analysis. Choice of value(s) to support economic models must be carefully justified to ensure a robust economic analysis.

Effects of an Empowerment Program on Self-Care Behaviors and Readmission of Patients with Heart Failure: a Randomized Clinical Trial

BACKGROUND

The prevalence of heart failure, as a serious health problem, is increasing around the world due to underlying factors, such as hypertension and diabetes. Although the patient's cooperation in the treatment process plays a crucial role in treatment, only a few combinations of different approaches have been investigated so far. This study aimed to determine the effects of an empowerment program on the patients' self-care behaviors and hospital readmission.

MATERIALS AND METHODS

In this randomized clinical trial, 120 patients with heart failure were divided into experimental and control groups. In the experimental group, the empowerment program, including face-to-face training, educational booklets, and follow-up via Telegram messaging application, was implemented, while the control group only received standard care. Data were collected before the intervention and six months after the intervention, using a researcher-made questionnaire. The Self-Care of Heart Failure Index (SCHFI) was completed for both groups.

RESULTS

The results indicated that all three self-care scales, namely, self-care maintenance, self-care management, and self-care confidence, significantly improved in the experimental group compared to the baseline (P=0.000), while the scores of these scales decreased in the control group (P=0.000). The frequency of hospital admission and the length of hospital stay also reduced in the experimental group (P=0.000 and P<0.001, respectively). There was no significant difference in terms of the demographic characteristics between the two groups.

CONCLUSION

The empowerment program significantly improved the patients' self-care behaviors and reduced the frequency and duration of hospitalization. Therefore, implementation of such programs is strongly suggested, especially in heart failure clinics.

The Effect of the Teach-Back Method on Knowledge, Performance, Readmission, and Quality of Life in Heart Failure Patients

Background

Among chronic diseases, heart failure has always been a serious challenge imposing high costs on health systems and societies. Therefore, nurses should adopt new educational strategies to improve self-care behaviors and reduce the readmissions in heart failure patients. This study aimed to determine the effect of the teach-back method on knowledge, performance, readmission, and quality of life in these patients.

Methods

This clinical trial was conducted in patients with heart failure (n = 70) hospitalized in the internal wards of the Baqiyatallah al-Azam Medical Center in Tehran (2019). Routine discharge educations were provided in control patients. Self-care topics were taught to the intervention groups by the teach-back method. A cardiac self-care questionnaire was used to assess the knowledge and practice of patients immediately after intervention and three months after patient discharge. Also, SF-36 was presented to each patient. Readmission(s) and quality of life were followed up by telephone interviews three months after patient discharge. Repeated measures analysis of variance and related post-hoc tests were performed for within-group comparisons before, immediately after, and 3 months after teach-back education. Wilks' lambda multivariate tests were conducted for simultaneous comparison of quality of life subscales between intervention and control groups. Also, logistic regressions were after controlling for baseline measures and confounders.

Results

Findings showed significant improvement in the patients' knowledge and performance immediately after teach-back education, though this effect was slow in the long term after discharge. Also, the frequency of readmissions decreased and the quality of life (except physical function) increased in the patients through teach-back education. By controlling for the pretest effect, the posttest scores for the relevant components of the quality of life suggested improvement in both intervention and control patients. This improvement in the quality of life was confirmed by controlling for baseline measurements using binary logistic regression analysis.

Conclusion

Teach-back education improved patients' knowledge and performance, readmission frequency, and quality of life.

The impact of pharmacist/physician care on quality of life in elderly heart failure patients: results of the PHARM-CHF randomized controlled trial

Aims

Patients with heart failure (HF) have impaired quality of life (QoL). The randomized controlled trial PHARM‐CHF investigated whether an interdisciplinary intervention consisting of regular contacts with the community pharmacy and weekly dosing aids improves medication adherence in patients with HF. It is unknown how an intervention involving frequent structured pharmacy visits affects QoL. Our aim was to explore adherence to the intervention and effects on QoL.

Methods and results

Among 237 patients, n = 110 were randomized to pharmacy care and n = 127 to usual care. The pharmacy care group received a medication review followed by (bi‐)weekly dose dispensing and counselling. The median follow‐up was 2.0 years [inter‐quartile range (IQR) 1.2–2.7]. Median interval between pharmacy visits was 8.4 days (IQR 8.0–10.3) and the visits lasted in median 14 min (IQR 10–15). Median adherence to the intervention was 96% (IQR 84–100). QoL at 365 days was predefined as a main secondary and at 730 days as another secondary endpoint in PHARM‐CHF. QoL was measured by the Minnesota Living with Heart Failure Questionnaire; and for 111 patients (n = 47 in the pharmacy care group and n = 64 in the usual care group), data were available at baseline, and after 365 and 730 days (mean age 74 years; 41% female). Improvement in QoL was numerically higher in the pharmacy care group after 365 days and was significantly better after 730 days (difference in total scores −7.7 points [−14.5 to −1.0]; P = 0.026) compared to the usual care group. In all subgroups examined, this treatment effect was preserved. Improvements in the physical and emotional dimensions were numerically higher in the pharmacy care group after 365 days and were significantly better after 730 days: −4.0 points [−6.9 to −1.2]; P = 0.006, and −1.9 points [−3.7 to −0.1]; P = 0.039, respectively.

Conclusions

A pharmacy‐based interdisciplinary intervention was well received by the patients and suggests clinically important improvements in QoL.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

Effectiveness of pharmacist home visits for individuals at risk of medication-related problems: a systematic review and meta-analysis of randomised controlled trials

Background

Medication mismanagement is a major cause of both hospital admission and nursing home placement of frail older adults. Medication reviews by community pharmacists aim to maximise therapeutic benefit but also minimise harm. Pharmacist-led medication reviews have been the focus of several systematic reviews, but none have focussed on the home setting.

Review methods

To determine the effectiveness of pharmacist home visits for individuals at risk of medication-related problems we undertook a systematic review and meta-analysis of randomised controlled trials (RCTs). Thirteen databases were searched from inception to December 2018. Forward and backward citation of included studies was also performed. Articles were screened for inclusion independently by two reviewers. Randomised controlled studies of home visits by pharmacists for individuals at risk of medication-related problems were eligible for inclusion. Data extraction and quality appraisal were performed by one reviewer and checked by a second. Random-effects meta-analyses were performed where sufficient data allowed and narrative synthesis summarised all remaining data.

Results

Twelve RCTs (reported in 15 articles), involving 3410 participants, were included in the review. The frequency, content and purpose of the home visit varied considerably. The data from eight trials were suitable for meta-analysis of the effects on hospital admissions and mortality, and from three trials for the effects on quality of life. Overall there was no evidence of reduction in hospital admissions (risk ratio (RR) of 1.01 (95%CI 0.86 to 1.20, I² = 69.0%, p = 0.89; 8 studies, 2314 participants)), or mortality (RR of 1.01 (95%CI 0.81 to 1.26, I² = 0%, p = 0.94; 8 studies, 2314 participants)). There was no consistent evidence of an effect on quality of life, medication adherence or knowledge.

Conclusion

A systematic review of twelve RCTs assessing the impact of pharmacist home visits for individuals at risk of medication related problems found no evidence of effect on hospital admission or mortality rates, and limited evidence of effect on quality of life. Future studies should focus on using more robust methods to assess relevant outcomes.

Rationale and design of a navigator-driven remote optimization of guideline-directed medical therapy in patients with heart failure with reduced ejection fraction

Although optimal pharmacological therapy for heart failure with reduced ejection fraction (HFrEF) is carefully scripted by treatment guidelines, many eligible patients are not treated with guideline‐directed medical therapy (GDMT) in clinical practice. We designed a strategy for remote optimization of GDMT on a population scale in patients with HFrEF leveraging nonphysician providers. An electronic health record‐based algorithm was used to identify a cohort of patients with a diagnosis of heart failure (HF) and ejection fraction (EF) ≤ 40% receiving longitudinal follow‐up at our center. Those with end‐stage HF requiring inotropic support, mechanical circulatory support, or transplantation and those enrolled in hospice or palliative care were excluded. Treating providers were approached for consent to adjust medical therapy according to a sequential, stepped titration algorithm modeled on the current American College of Cardiology (ACC)/American Heart Association (AHA) HF Guidelines within a collaborative care agreement. The program was approved by the institutional review board at Brigham and Women's Hospital with a waiver of written informed consent. All patients provided verbal consent to participate. A navigator then facilitated medication adjustments by telephone and conducted longitudinal surveillance of laboratories, blood pressure, and symptoms. Each titration step was reviewed by a pharmacist with supervision as needed from a nurse practitioner and HF cardiologist. Patients were discharged from the program to their primary cardiologist after achievement of an optimal or maximally tolerated regimen. A navigator‐led remote management strategy for optimization of GDMT may represent a scalable population‐level strategy for closing the gap between guidelines and clinical practice in patients with HFrEF.

Cost Effectiveness of Advanced Pharmacy Services Provided in the Community and Primary Care Settings: A Systematic Review

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.

Effect of home-based follow-up intervention on readmissions and mortality in heart failure patients: a meta-analysis

Aim: We investigated whether the home-based intervention (HBI) for heart failure (HF), restricted to education and support, improves readmissions or mortality compared with usual care. Patients & methods: We searched PubMed and Embase for randomized controlled trials that examined the impact of HBI in HF. A random-effects meta-analysis was performed using R. Result: Total 17/409 articles (3214 patients) met our inclusion criteria. The pooled estimate showed HBI was associated with a reduction in readmission rates and mortality (22 and 16% respectively; p < 0.05). Subgroup analysis confirmed that the benefit of HBI increases significantly with a longer follow-up. Conclusion: HBI in the form of education and support significantly reduces readmission rates and improves survival of HF patients. HBI should be considered in the discharge planning of HF patients.

Cardiovascular disease as a leading cause of death: how are pharmacists getting involved?

Cardiovascular diseases (CVDs) are a leading cause of death globally. This article explores the evidence surrounding community pharmacist interventions to reduce cardiovascular events and related mortality and to improve the management of CVD risk factors. We summarize a range of systematic reviews and leading randomized controlled trials and provide critical appraisal. Major observations are that very few trials directly measure clinical outcomes, potentially owing to a range of challenges in this regard. By contrast, there is an extensive, high-quality evidence to suggest that improvements can be achieved for key CVD risk factors such as hypertension, dyslipidemia, tobacco use, and elevated hemoglobin A1c. The heterogeneity of interventions tested and considerable variation of the context under which implementation occurred suggest that caution is warranted in the interpretation of meta-analyses. It is highly important to generate evidence for pharmacist interventions in developing countries where a majority of the global CVD burden will be experienced in the near future. A growing capacity for clinical registry trials and data linkage might allow future research to collect clinical outcomes data more often.

Disease management interventions for heart failure

BACKGROUND

Despite advances in treatment, the increasing and ageing population makes heart failure an important cause of morbidity and death worldwide. It is associated with high healthcare costs, partly driven by frequent hospital readmissions. Disease management interventions may help to manage people with heart failure in a more proactive, preventative way than drug therapy alone. This is the second update of a review published in 2005 and updated in 2012.

OBJECTIVES

To compare the effects of different disease management interventions for heart failure (which are not purely educational in focus), with usual care, in terms of death, hospital readmissions, quality of life and cost-related outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL for this review update on 9 January 2018 and two clinical trials registries on 4 July 2018. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least six months' follow-up, comparing disease management interventions to usual care for adults who had been admitted to hospital at least once with a diagnosis of heart failure. There were three main types of intervention: case management; clinic-based interventions; multidisciplinary interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Outcomes of interest were mortality due to heart failure, mortality due to any cause, hospital readmission for heart failure, hospital readmission for any cause, adverse effects, quality of life, costs and cost-effectiveness.

MAIN RESULTS

We found 22 new RCTs, so now include 47 RCTs (10,869 participants). Twenty-eight were case management interventions, seven were clinic-based models, nine were multidisciplinary interventions, and three could not be categorised as any of these. The included studies were predominantly in an older population, with most studies reporting a mean age of between 67 and 80 years. Seven RCTs were in upper-middle-income countries, the rest were in high-income countries.Only two multidisciplinary-intervention RCTs reported mortality due to heart failure. Pooled analysis gave a risk ratio (RR) of 0.46 (95% confidence interval (CI) 0.23 to 0.95), but the very low-quality evidence means we are uncertain of the effect on mortality due to heart failure. Based on this limited evidence, the number needed to treat for an additional beneficial outcome (NNTB) is 12 (95% CI 9 to 126).Twenty-six case management RCTs reported all-cause mortality, with low-quality evidence indicating that these may reduce all-cause mortality (RR 0.78, 95% CI 0.68 to 0.90; NNTB 25, 95% CI 17 to 54). We pooled all seven clinic-based studies, with low-quality evidence suggesting they may make little to no difference to all-cause mortality. Pooled analysis of eight multidisciplinary studies gave moderate-quality evidence that these probably reduce all-cause mortality (RR 0.67, 95% CI 0.54 to 0.83; NNTB 17, 95% CI 12 to 32).We pooled data on heart failure readmissions from 12 case management studies. Moderate-quality evidence suggests that they probably reduce heart failure readmissions (RR 0.64, 95% CI 0.53 to 0.78; NNTB 8, 95% CI 6 to 13). We were able to pool only two clinic-based studies, and the moderate-quality evidence suggested that there is probably little or no difference in heart failure readmissions between clinic-based interventions and usual care (RR 1.01, 95% CI 0.87 to 1.18). Pooled analysis of five multidisciplinary interventions gave low-quality evidence that these may reduce the risk of heart failure readmissions (RR 0.68, 95% CI 0.50 to 0.92; NNTB 11, 95% CI 7 to 44).Meta-analysis of 14 RCTs gave moderate-quality evidence that case management probably slightly reduces all-cause readmissions (RR 0.92, 95% CI 0.83 to 1.01); a decrease from 491 to 451 in 1000 people (95% CI 407 to 495). Pooling four clinic-based RCTs gave low-quality and somewhat heterogeneous evidence that these may result in little or no difference in all-cause readmissions (RR 0.90, 95% CI 0.72 to 1.12). Low-quality evidence from five RCTs indicated that multidisciplinary interventions may slightly reduce all-cause readmissions (RR 0.85, 95% CI 0.71 to 1.01); a decrease from 450 to 383 in 1000 people (95% CI 320 to 455).Neither case management nor clinic-based intervention RCTs reported adverse effects. Two multidisciplinary interventions reported that no adverse events occurred. GRADE assessment of moderate quality suggested that there may be little or no difference in adverse effects between multidisciplinary interventions and usual care.Quality of life was generally poorly reported, with high attrition. Low-quality evidence means we are uncertain about the effect of case management and multidisciplinary interventions on quality of life. Four clinic-based studies reported quality of life but we could not pool them due to differences in reporting. Low-quality evidence indicates that clinic-based interventions may result in little or no difference in quality of life.Four case management programmes had cost-effectiveness analyses, and seven reported cost data. Low-quality evidence indicates that these may reduce costs and may be cost-effective. Two clinic-based studies reported cost savings. Low-quality evidence indicates that clinic-based interventions may reduce costs slightly. Low-quality data from one multidisciplinary intervention suggested this may be cost-effective from a societal perspective but less so from a health-services perspective.

AUTHORS' CONCLUSIONS

We found limited evidence for the effect of disease management programmes on mortality due to heart failure, with few studies reporting this outcome. Case management may reduce all-cause mortality, and multidisciplinary interventions probably also reduce all-cause mortality, but clinic-based interventions had little or no effect on all-cause mortality. Readmissions due to heart failure or any cause were probably reduced by case-management interventions. Clinic-based interventions probably make little or no difference to heart failure readmissions and may result in little or no difference in readmissions for any cause. Multidisciplinary interventions may reduce the risk of readmission for heart failure or for any cause. There was a lack of evidence for adverse effects, and conclusions on quality of life remain uncertain due to poor-quality data. Variations in study location and time of occurrence hamper attempts to review costs and cost-effectiveness.The potential to improve quality of life is an important consideration but remains poorly reported. Improved reporting in future trials would strengthen the evidence for this patient-relevant outcome.

Current perspectives on pharmacist home visits: do we keep reinventing the wheel?

The scope of clinical pharmacy services available in outpatient settings, including home care, continues to expand. This review sought to identify the evidence to support pharmacist provision of clinical pharmacy services in a home care setting. Seventy-five reports were identified in the literature that provided evaluation and description of clinical pharmacy home visit services available around the world. Based on results from randomized controlled trials, pharmacist home visit interventions can improve patient medication adherence and knowledge, but have little impact on health care resource utilization. Other literature reported benefits of a pharmacist home visit service such as patient satisfaction, improved medication appropriateness, increased persistence with warfarin therapy, and increased medication discrepancy resolution. Current perspectives to consider in establishing or evaluating clinical pharmacy services offered in a home care setting include: staff competency, ideal target patient population, staff safety, use of technology, collaborative relationships with other health care providers, activities performed during a home visit, and pharmacist autonomy.

Burnout, compassion fatigue and psychological capital: Findings from a survey of nurses delivering palliative care

BACKGROUND

Ageing populations worldwide and a concomitant increase in chronic conditions translates into an increased demand for the delivery of palliative and end of life care by nurses. This increasing demand for palliative care provision may produce stressors resulting in negative outcomes such as burnout and compassion fatigue.

AIM

The purpose of this study was to explore burnout and compassion fatigue, as well as potential protective factors, among nurses in New Zealand.

METHODS

An online survey was conducted with 256 registered nurses (between January 2016 and February 2017) recruited through nursing organisations and a large tertiary level hospital. Data analysis consisted of descriptive statistics, multivariate analysis of variance, Pearson correlations, and hierarchical multiple regression.

RESULTS

Psychological empowerment and the commitment and challenge components of psychological hardiness significantly predicted lower scores for the burnout while previous palliative care education and challenge predicted lower scores for the secondary traumatic stress component of compassion fatigue. Significant predictors of compassion satisfaction included previous palliative care education, psychological empowerment and both the commitment and challenge components of psychological hardiness.

CONCLUSION

Nurses draw upon unique combinations of "psychological capital" to deal with caring for patients with life-limiting illnesses. Any interventions to increase nurse palliative care education uptake must be tailored to develop and support these internal resources.

Pharmacist-led intervention in the multidisciplinary team approach optimizes heart failure medication

We evaluated the impact of pharmacist-led heart failure (HF) drug recommendations during hospitalization for hospitalized patients with HF. Hospitalized patients with HF were retrospectively reviewed. Patients were hospitalized before (n = 208, non-intervention group) or after (n = 170, intervention group) the launch of the HF multidisciplinary team (HFMDT) approach with pharmacist-led HF medication optimization. There were no significant group differences in patient background characteristics at admission. Patients with HF with reduced ejection fraction who were not on beta blockers or angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (ACE-I/ARB) at admission were significantly more likely to be on beta blockers at the time of discharge in the intervention group (73.3 vs 96.3%, P = 0.027) compared to those in non-intervention group; however, the change in ACE-I/ARB prescriptions was not significant (53.3 vs 63.3%, P = 0.601). The proportion of patients on any drug with recommendations against its use in patients with HF did not change from admission to discharge in the non-intervention group (21.2 vs. 20.2%, P = 0.855), but was significantly reduced in the intervention group (22.9 vs. 12.9%, P = 0.005). There were no group differences in the in-hospital all-cause mortality (non-intervention, 3.4%; intervention, 2.4%; P = 0.761) or length of hospital stay (median: non-intervention, 13 days; intervention, 14 days; P = 0.508). Pharmacist-led HF drug recommendations during hospitalization as part of a HFMDT approach for hospitalized patients with HF can increase beta blocker prescriptions and decrease non-preferred drug prescriptions.

Randomized controlled trials covering pharmaceutical care and medicines management: A systematic review of literature

OBJECTIVE

To review the effects of pharmaceutical care on hospitalizations, mortality and clinical outcomes in patients.

METHODS

Systematic searches were conducted in MEDLINE, EMBASE and International Pharmaceutical Abstracts (IPA) databases to identify studies that were published between 2004 and January 2017. Studies included in this review were randomized controlled trials (RCTs) that spanned across both community and hospital settings. Using strict inclusion/exclusion criteria studies were included if they reported level 1 or 2 outcomes in the hierarchy of outcome measure i.e. clinical and surrogate outcomes (e.g. blood pressure (BP) control, blood glucose level, cholesterol BMI). Each study was assessed for quality using the Jadad scoring system.

RESULTS

Fifty-four RCTs were included in the present review. Forty-six of these studies ranked high quality according to the Jadad scoring system. Studies were categorized into their general condition groups. Interventions in patients with diabetes, depression, respiratory disorders, cardiovascular disorders, epilepsy, osteoporosis, and interventions in older adults were identified. In the majority of studies pharmaceutical care was found to lead to significant improvements in clinical outcomes and/or hospitalizations when compared to the non-intervention group. Some conditions had a large number of RCTs, for example for cardiovascular conditions and in diabetes. Statistically significant improvements were seen in the majority of the studies included for both of these conditions, with studies indicating positive clinical outcomes and/or hospitalizations rates. Within the cardiovascular condition, a subset of studies, focusing on cardiac heart failure and coronary heart disease, had more mixed results. In other conditions the number of RCTs conducted was small and the evidence did not show improvements after pharmaceutical care, i.e. in depression, osteoporosis, and epilepsy. The majority of interventions were face to face interactions with patients, whilst a smaller number were conducted via the telephone and one via a web-based system. Patient education was a key component of most interventions, either verbal and/or written. Longitudinal data, post intervention cessation, was not collected in the majority of cases.

CONCLUSIONS

RCTs conducted to evaluate pharmaceutical care appear to be effective in improving patient short-term outcomes for a number of conditions including diabetes and cardiovascular conditions, however, other conditions such as depression are less well researched. Future research should attempt to evaluate the conditions where there is a lack of data, whether the positive effects of pharmaceutical care persist in patient populations after the interventions cease and what the long-term clinical outcomes would be of continued pharmaceutical care.

Disease management in the treatment of patients with chronic heart failure who have universal access to health care: a randomized controlled trial

BACKGROUND

The efficacy of disease management programs in improving the outcome of heart failure patients remains uncertain and may vary across health systems. This study explores whether a countrywide disease management program is superior to usual care in reducing adverse health outcomes and improving well-being among community-dwelling adult patients with moderate-to-severe chronic heart failure who have universal access to advanced health-care services and technologies.

METHODS

In this multicenter open-label trial, 1,360 patients recruited after hospitalization for heart failure exacerbation (38%) or from the community (62%) were randomly assigned to either disease management or usual care. Disease management, delivered by multi-disciplinary teams, included coordination of care, patient education, monitoring disease symptoms and patient adherence to medication regimen, titration of drug therapy, and home tele-monitoring of body weight, blood pressure and heart rate. Patients assigned to usual care were treated by primary care practitioners and consultant cardiologists. The primary composite endpoint was the time elapsed till first hospital admission for heart failure exacerbation or death from any cause. Secondary endpoints included the number of all hospital admissions, health-related quality of life and depression during follow-up. Intention-to-treat comparisons between treatments were adjusted for baseline patient data and study center.

RESULTS

During the follow-up, 388 (56.9%) patients assigned to disease management and 387 (57.1%) assigned to usual care had a primary endpoint event. The median (range) time elapsed until the primary endpoint event or end of study was 2.0 (0-5.0) years among patients assigned to disease management, and 1.8 (0-5.0) years among patients assigned to usual care (adjusted hazard ratio, 0.908; 95% confidence interval, 0.788 to 1.047). Hospital admissions were mostly (70%) unrelated to heart failure. Patients assigned to disease management had a better health-related quality of life and a lower depression score during follow-up.

CONCLUSIONS

This comprehensive disease management intervention was not superior to usual care with respect to the primary composite endpoint, but it improved health-related quality of life and depression. A disease-centered approach may not suffice to make a significant impact on hospital admissions and mortality in patients with chronic heart failure who have universal access to health care.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT00533013 . Trial registration date: 9 August 2007. Initial protocol release date: 20 September 2007.

Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis

AIMS

To compare the effectiveness of transitional care services in decreasing all-cause death and all-cause readmissions following hospitalization for heart failure (HF).

METHODS AND RESULTS

We searched PubMed, Embase, CINAHL, and Cochrane Clinical Trials Register for randomized controlled trials (RCTs) published in 2000-2015 that tested the efficacy of transitional care services in patients hospitalized for HF, provided ≥1 month of follow-up, and reported all-cause mortality or all-cause readmissions. Our network meta-analysis included 53 RCTs (12 356 patients). Among services that significantly decreased all-cause mortality compared with usual care, nurse home visits were most effective [ranking P-score 0.6794; relative risk (RR) 0.78, 95% confidence intervals (CI) 0.62-0.98], followed by disease management clinics (DMCs) (ranking P-score 0.6368; RR 0.80, 95% CI 0.67-0.97). Among services that significantly decreased all-cause readmission, nurse home visits were most effective [ranking P-score 0.8365; incident rate ratio (IRR) 0.65, 95% CI 0.49-0.86], followed by nurse case management (NCM) (ranking P-score 0.6168; IRR 0.77, 95% CI 0.63-0.95), and DMCs (ranking P-score 0.5691; IRR 0.80, 95% CI 0.66-0.97). There was no significant difference in the comparative effectiveness of services that improved each outcome. Nurse home visits had the greatest pooled cost-savings (3810 USD, 95% CI 3682-3937), followed by NCM (3435 USD, 95% CI 3224-3645), and DMCs (245 USD, 95% CI -70 to 559). Telephone, telemonitoring, pharmacist, and education interventions did not significantly improve clinical outcomes.

CONCLUSION

Nurse home visits and DMCs decrease all-cause mortality after hospitalization for HF. Along with NCM, they also reduce all-cause readmissions, with no significant difference in comparative effectiveness. These services reduce healthcare system costs to varying degrees.

Financial aspects of community pharmacies in Slovakia (2009-2014) Finančné aspekty verejných lekární na Slovensku v rokoch 2009-2014

Community pharmacies play an important role in the process of ensuring public health. Pharmacists provide pharmaceutical care that includes acquiring, storing, preparing, reviewing and dispensing medicines, medical devices and dietary food to the inhabitants; providing them with information and advice; acquiring, storing and dispensing additional assortment; carrying out physical and biochemical testing for primary prevention and monitoring of drug efficacy and safety. At present, there are constant changes which have direct or potential and often negative impact on community pharmacies. For providing affordable and good quality pharmaceutical care, it is important to continuously monitor and analyse the developments in the financial data in community pharmacy business management. The data file from 2009-2014 on financial performance of selected community pharmacies were obtained from the Register of Financial Statements at Ministry of Finance Slovak Republic. A group of 194 community pharmacies were selected that represented more than 10 percent of all pharmacies. The selection criteria respected the territorial division of the Slovak Republic on districts, the size of municipalities (cities and villages) and location (at or near health centres, shopping centres, housing estates, etc.). The evaluation parameters were gross profit, net profit, revenue from sales of goods and services, operating expenses, total assets, inventory, short-term receivables, total receivables, financial assets, owner’s equity, total liabilities, current liabilities and their characteristics (25th, 50th, 75th percentile, minimum, maximum, mean). The financial parameters obtained and their characteristics presented the basic information on the management of community pharmacies. The data also provided information for further assessment on factors that might have an impact on their value and direction of evolution.

Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care

BACKGROUND

A range of health workforce strategies are needed to address health service demands in low-, middle- and high-income countries. Non-medical prescribing involves nurses, pharmacists, allied health professionals, and physician assistants substituting for doctors in a prescribing role, and this is one approach to improve access to medicines.

OBJECTIVES

To assess clinical, patient-reported, and resource use outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care).

SEARCH METHODS

We searched databases including CENTRAL, MEDLINE, Embase, and five other databases on 19 July 2016. We also searched the grey literature and handsearched bibliographies of relevant papers and publications.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after (CBA) studies (with at least two intervention and two control sites) and interrupted time series analysis (with at least three observations before and after the intervention) comparing: 1. non-medical prescribing versus medical prescribing in acute care; 2. non-medical prescribing versus medical prescribing in chronic care; 3. non-medical prescribing versus medical prescribing in secondary care; 4 non-medical prescribing versus medical prescribing in primary care; 5. comparisons between different non-medical prescriber groups; and 6. non-medical healthcare providers with formal prescribing training versus those without formal prescribing training.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed studies for inclusion, extracted data, and assessed study quality with discrepancies resolved by discussion. Two review authors independently assessed risk of bias for the included studies according to EPOC criteria. We undertook meta-analyses using the fixed-effect model where studies were examining the same treatment effect and to account for small sample sizes. We compared outcomes to a random-effects model where clinical or statistical heterogeneity existed.

MAIN RESULTS

We included 46 studies (37,337 participants); non-medical prescribing was undertaken by nurses in 26 studies and pharmacists in 20 studies. In 45 studies non-medical prescribing as a component of care was compared with usual care medical prescribing. A further study compared nurse prescribing supported by guidelines with usual nurse prescribing care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location.A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, and low-density lipoprotein) showed positive intervention group effects. There was a moderate-certainty of evidence for studies of blood pressure at 12 months (mean difference (MD) -5.31 mmHg, 95% confidence interval (CI) -6.46 to -4.16; 12 studies, 4229 participants) and low-density lipoprotein (MD -0.21, 95% CI -0.29 to -0.14; 7 studies, 1469 participants); we downgraded the certainty of evidence from high due to considerations of serious inconsistency (considerable heterogeneity), multifaceted interventions, and variable prescribing autonomy. A high-certainty of evidence existed for comparative studies of glycated haemoglobin management at 12 months (MD -0.62, 95% CI -0.85 to -0.38; 6 studies, 775 participants). While there appeared little difference in medication adherence across studies, a meta-analysis of continuous outcome data from four studies showed an effect favouring patient adherence in the non-medical prescribing group (MD 0.15, 95% CI 0.00 to 0.30; 4 studies, 700 participants). We downgraded the certainty of evidence for adherence to moderate due to the serious risk of performance bias. While little difference was seen in patient-related adverse events between treatment groups, we downgraded the certainty of evidence to low due to indirectness, as the range of adverse events may not be related to the intervention and selective reporting failed to adequately report adverse events in many studies.Patients were generally satisfied with non-medical prescriber care (14 studies, 7514 participants). We downgraded the certainty of evidence from high to moderate due to indirectness, in that satisfaction with the prescribing component of care was only addressed in one study, and there was variability of satisfaction measures with little use of validated tools. A meta-analysis of health-related quality of life scores (SF-12 and SF-36) found a difference favouring usual care for the physical component score (MD 1.17, 95% CI 0.16 to 2.17), but not the mental component score (MD 0.58, 95% CI -0.40 to 1.55). However, the quality of life measurement may more appropriately reflect composite care rather than the prescribing component of care, and for this reason we downgraded the certainty of evidence to moderate due to indirectness of the measure of effect. A wide variety of resource use measures were reported across studies with little difference between groups for hospitalisations, emergency department visits, and outpatient visits. In the majority of studies reporting medication use, non-medical prescribers prescribed more drugs, intensified drug doses, and used a greater variety of drugs compared to usual care medical prescribers.The risk of bias across studies was generally low for selection bias (random sequence generation), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting). There was an unclear risk of selection bias (allocation concealment) and for other biases. A high risk of performance bias (blinding of participants and personnel) existed.

AUTHORS' CONCLUSIONS

The findings suggest that non-medical prescribers, practising with varying but high levels of prescribing autonomy, in a range of settings, were as effective as usual care medical prescribers. Non-medical prescribers can deliver comparable outcomes for systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction, and health-related quality of life. It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. Future efforts should be directed towards more rigorous studies that can clearly identify the clinical, patient-reported, resource use, and economic outcomes of non-medical prescribing, in both high-income and low-income countries.

A feasibility study: Use of actigraph to monitor and follow-up sleep/wake patterns in individuals attending community pharmacy with sleeping disorders

Introduction:

Community pharmacists are in a suitable position to give advice and provide appropriate services related to sleep disorders to individuals who are unable to easily access sleep clinics. An intervention with proper objective measure can be used by the pharmacist to assist in consultation.

Objectives:

The study objectives are to evaluate: (1) The effectiveness of a community pharmacy-based intervention in managing sleep disorders and (2) the role of actigraph as an objective measure to monitor and follow-up individuals with sleeping disorders.

Methods and Instruments:

The intervention care group (ICG) completed questionnaires to assess sleep scale scores (Epworth Sleepiness Scale [ESS] and Insomnia Severity Index [ISI]), wore a wrist actigraph, and completed a sleep diary. Sleep parameters (sleep efficiency in percentage [SE%], total sleep time, sleep onset latency, and number of nocturnal awakenings) from actigraphy sleep report were used for consultation and to validate sleep diary. The usual care group (UCG) completed similar questionnaires but received standard care.

Results:

Pre- and post-mean scores for sleep scales and sleep parameters were compared between and within groups. A significant difference was observed when comparing pre- and post-mean scores for ISI in the ICG, but not for ESS. For SE%, an increase was found in the number of subjects rated as “good sleepers” at post-assessment in the ICG.

Conclusions:

ISI scores offer insights into the development of a community pharmacy-based intervention for sleeping disorders, particularly in those with symptoms of insomnia. It also demonstrates that actigraph could provide objective sleep/wake data to assist community pharmacists during the consultation.

The feasibility of determining the effectiveness and cost-effectiveness of medication organisation devices compared with usual care for older people in a community setting: systematic review, stakeholder focus groups and feasibility randomised controlled trial

BACKGROUND

Medication organisation devices (MODs) provide compartments for a patient's medication to be organised into the days of the week and the recommended times the medication should be taken.

AIM

To define the optimal trial design for testing the clinical effectiveness and cost-effectiveness of MODs.

DESIGN

The feasibility study comprised a systematic review and focus groups to inform a randomised controlled trial (RCT) design. The resulting features were tested on a small scale, using a 2 × 2 factorial design to compare MODs with usual packaging and to compare weekly with monthly supply. The study design was then evaluated.

SETTING

Potential participants were identified by medical practices.

PARTICIPANTS

Aged over 75 years, prescribed at least three solid oral dosage form medications, unintentionally non-adherent and self-medicating. Participants were excluded if deemed by their health-care team to be unsuitable.

INTERVENTIONS

One of three MODs widely used in routine clinical practice supplied either weekly or monthly.

OBJECTIVES

To identify the most effective method of participant recruitment, to estimate the prevalence of intentional and unintentional non-adherence in an older population, to provide a point estimate of the effect size of MODs relative to usual care and to determine the feasibility and acceptability of trial participation.

METHODS

The systematic review included MOD studies of any design reporting medication adherence, health and social outcomes, resource utilisation or dispensing or administration errors. Focus groups with patients, carers and health-care professionals supplemented the systematic review to inform the RCT design. The resulting design was implemented and then evaluated through questionnaires and group discussions with participants and health-care professionals involved in trial delivery.

RESULTS

Studies on MODs are largely of poor quality. The relationship between adherence and health outcomes is unclear. Of the limited studies reporting health outcomes, some reported a positive relationship while some reported increased hospitalisations associated with MODs. The pre-trial focus groups endorsed the planned study design, but suggested a minimum recruitment age of 50-60 years. A total of 35.4% of patients completing the baseline questionnaire were excluded because they already used a MOD. Active recruitment yielded a higher consent rate, but passive recruitment was more cost-effective. The prevalence of intentional non-adherence was 24.7% [n = 71, 95% confidence interval (CI) 19.7% to 29.6%] of participants. Of the remaining 76 participants, 46.1% (95% CI 34.8% to 57.3%) were unintentionally non-adherent. There was no indication of a difference in adherence between the study arms. Participants reported a high level of satisfaction with the design. Five adverse/serious adverse events were identified in the MOD study arms and none was identified in the control arms. There was no discernible difference in health economic outcomes between the four study arms; the mean intervention cost was £20 per month greater for MOD monthly relative to usual supply monthly.

CONCLUSIONS

MOD provision to unintentionally non-adherent older people may cause medication-related adverse events. The primary outcome for a definitive MOD trial should be health outcomes. Such a trial should recruit patients by postal invitation and recruit younger patients.

FUTURE WORK

A study examining the association between MOD initiation and adverse effects is necessary and a strategy to safely introduce MODs should be explored. A definitive study testing the clinical effectiveness and cost-effectiveness of MODs is also required.

STUDY REGISTRATION

Current Controlled Trials ISRCTN 30626972 and UKCRN 12739.

FUNDING

This project was funded by National Institute for Health Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 20, No. 50. See the NIHR Journals Library website for further project information.

Impact of Pharmaceutical Care Interventions on Health-Related Quality-of-Life Outcomes: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the impact of pharmaceutical care (PC) interventions on health-related quality of life (HRQoL) and determine sensitivity of HRQoL measures to PC services.

DATA SOURCES

MEDLINE, EMBASE, International Pharmaceutical Abstracts, PubMed, Global Health, PsychINFO, CINAHL, and Web of Science (January 2005 to September 2015) were searched.

STUDY SELECTION AND DATA EXTRACTION

Original English-language articles were included if PC impact on HRQoL was evaluated and reported using validated HRQoL measures.

DATA SYNTHESIS

A total of 31 randomized controlled trials, 9 nonrandomized studies with comparison groups, and 8 before-after studies were included. PC interventions resulted in significant improvement in 1 domain and ≥3 domains of HRQoL measures in 66.7% and 27.1% of the studies, respectively. There was a significant improvement in at least 1 domain in 18 of 32 studies using generic and 16 of 21 studies using disease-specific measures. When the Short Form 36 Items Health Survey (SF-36) measure was used, PC interventions had a moderate impact on social functioning (standardized mean difference [SMD] = 0.59; 95% CI = 0.14, 1.04), general health (SMD = 0.36; 95% CI = 0.12, 0.59), and physical functioning (SMD = 0.30; 95% CI = 0.11, 0.48). The pooled data on heart failure-specific (SMD = -0.17; 95% CI = -0.43, 0.09), asthma-specific (SMD = 0.17; 95% CI = -0.03, 0.36), and chronic obstructive pulmonary disease-specific (SMD = -0.09; 95% CI = -0.37, 0.19) measures indicated no significant impact of PC on HRQoL.

CONCLUSIONS

PC interventions can significantly improve at least 1 domain of HRQoL. Existing measures may have minimal to moderate sensitivity to PC interventions, with evidence pointing more toward social functioning, general health, and physical functioning of the SF-36 measure. However, evidence generated from current non-PC-specific HRQoL measures is insufficient to judge the impact of PC interventions on HRQoL. The development of a suitable HRQoL measure for PC interventions may help generate better evidence for the contribution of pharmacist services to improving HRQoL.

Improving Treatment Adherence in Heart Failure

BACKGROUND

Despite improved treatment options, heart failure remains the third most common cause of death in Germany and the most common reason for hospitalization. The treatment recommendations contained in the relevant guidelines have been incompletely applied in practice. The goal of this systematic review is to study the efficacy of adherence-promoting interventions for patients with heart failure with respect to the taking of medications, the implementation of recommended lifestyle changes, and the improvement in clinical endpoints.

METHODS

We performed a meta-analysis of pertinent publications retrieved by a systematic literature search.

RESULTS

55 randomized controlled trials were identified, in which a wide variety of interventions were carried out on heterogeneous patient groups with varying definitions of adherence. These trials included a total of 15 016 patients with heart failure who were cared for as either inpatients or outpatients. The efficacy of interventions to promote adherence to drug treatment was studied in 24 trials; these trials documented improved adherence in 10% of the patients overall (95% confidence interval [CI]: [5; 15]). The efficacy of interventions to promote adherence to lifestyle recommendations was studied in 42 trials; improved adherence was found in 31 trials. Improved adherence to at least one recommendation yielded a long-term absolute reduction in mortality of 2% (95% CI: [0; 4]) and a 10% reduction in the likelihood of hospitalization within 12 months of the start of the intervention (95% CI: [3; 17]).

CONCLUSION

Many effective interventions are available that can lead to sustained improvement in patient adherence and in clinical endpoints. Longterm success depends on patients' assuming responsibility for their own health and can be achieved with the aid of coordinated measures such as patient education and regular follow-up contacts.

Medication Adherence Interventions Improve Heart Failure Mortality and Readmission Rates: Systematic Review and Meta-Analysis of Controlled Trials

BACKGROUND

Poor adherence to medications is a common problem among heart failure (HF) patients. Inadequate adherence leads to increased HF exacerbations, reduced physical function, and higher risk for hospital admission and death. Many interventions have been tested to improve adherence to HF medications, but the overall impact of such interventions on readmissions and mortality is unknown.

METHODS AND RESULTS

We conducted a comprehensive search and systematic review of intervention studies testing interventions to improve adherence to HF medications. Mortality and readmission outcome effect sizes (ESs) were calculated from the reported data. ESs were combined using random-effects model meta-analysis methods, because differences in true between-study effects were expected from variation in study populations and interventions. ES differences attributed to study design, sample, and intervention characteristics were assessed using moderator analyses when sufficient data were available. We assessed publication bias using funnel plots. Comprehensive searches yielded 6665 individual citations, which ultimately yielded 57 eligible studies. Overall, medication adherence interventions were found to significantly reduce mortality risk among HF patients (relative risk, 0.89; 95% CI, 0.81, 0.99), and decrease the odds for hospital readmission (odds ratio, 0.79; 95% CI, 0.71, 0.89). Heterogeneity was low. Moderator analyses did not detect differences in ES from common sources of potential study bias.

CONCLUSIONS

Interventions to improve medication adherence among HF patients have significant effects on reducing readmissions and decreasing mortality. Medication adherence should be addressed in regular follow-up visits with HF patients, and interventions to improve adherence should be a key part of HF self-care programs.

Clinical pharmacist home visits and 30-day readmissions in Medicare Advantage beneficiaries

RATIONALE, AIMS & OBJECTIVES

A variety of transition of care interventions has been evaluated to date to reduce readmissions. No studies evaluated effectiveness of clinical pharmacist's home-visits to recently discharged Medicare Advantage patients with the goal of preventing subsequent readmissions and urgent care use. The objective of this study was to evaluate the effectiveness of in-home clinical pharmacist's transition of care program on 30-day all-cause readmissions, emergency department (ED) visits, outpatient visits, as well as to assess patient satisfaction with the program.

METHODS

The study used retrospective cohort design.

RESULTS

A total of 245 patients were included in the study (mean (SD) age 77.8 (8.7); mean Charlson's Comorbidity Index 5.0 (2.5); 53.5% male). Forty-seven patients (19.0%) experienced at least one ED visit and twenty-two patients (9.0%) were readmitted within 30 days. The two groups did not differ on available demographic and clinical characteristics (p > 0.05). There was no difference in 30-day readmission rates, percent of patients with ≥1 ED visit, ≥1 outpatient physician office visit between the groups (p > 0.05). A total of 78 program participants responded to a satisfaction survey with 95% agreeing the program helped to stay healthy at home.

CONCLUSION

Multiple medication-related problems were identified by in-home pharmacists and the program appeared to be well-accepted by participants. In this study we did not find that the program had an impact on reduction of inpatient or urgent healthcare use. Further research using a different study design and a larger sample to estimate the program effectiveness is warranted.

A critical analysis of the implementation of service user involvement in primary care research and health service development using normalization process theory

BACKGROUND

There have been recent important advances in conceptualizing and operationalizing involvement in health research and health-care service development. However, problems persist in the field that impact on the scope for meaningful involvement to become a routine - normalized - way of working in primary care. In this review, we focus on current practice to critically interrogate factors known to be relevant for normalization - definition, enrolment, enactment and appraisal.

METHOD

Ours was a multidisciplinary, interagency team, with community representation. We searched EBSCO host for papers from 2007 to 2011 and engaged in an iterative, reflexive approach to sampling, appraising and analysing the literature following the principles of a critical interpretive synthesis approach and using Normalization Process Theory.

FINDINGS

Twenty-six papers were chosen from 289 papers, as a purposeful sample of work that is reported as service user involvement in the field. Few papers provided a clear working definition of service user involvement. The dominant identified rationale for enrolling service users in primary care projects was linked with policy imperatives for co-governance and emancipatory ideals. The majority of methodologies employed were standard health services research methods that do not qualify as research with service users. This indicates a lack of congruence between the stated aims and methods. Most studies only reported positive outcomes, raising questions about the balance or completeness of the published appraisals.

CONCLUSION

To improve normalization of meaningful involvement in primary care, it is necessary to encourage explicit reporting of definitions, methodological innovation to enhance co-governance and dissemination of research processes and findings.

The effect of family training and support on the quality of life and cost of hospital readmissions in congestive heart failure patients in Iran

BACKGROUND

This study was conducted to investigate the effects of family training and support on quality of life and cost of hospital readmissions in congestive heart failure patients.

METHODS

In this single-blinded, randomized, controlled trial, the participants were heart failure patients hospitalized in an Iranian hospital. Data were collected from available hospitalized patients. The participants were enrolled through randomized sampling and were divided randomly into two groups, an intervention group and a control group. The intervention group received extra training package for the disease. Training was provided at discharge and three months after. A standard questionnaire to assess the QoL was filled out by both groups at discharge and six months after.

RESULTS

Mean scores of QoL domains at the beginning of the study decreased in control group and increased in intervention in comparison with six months after (p<0.01).

CONCLUSION

Nursing care follow-up according to heart failure patients' needs promoted their QoL.