Immunosuppressant adherence after heart transplantation: a review on detection, prevention, and intervention strategies in a multidisciplinary

Heart transplantation is an effective treatment for end-stage heart disease, and postoperative patients' medication adherence is crucial for transplantation outcomes and long-term survival. By reviewing a large amount of related literature, this review summarizes the current status, evaluation methods, influencing factors, and intervention strategies of medication adherence after heart transplantation, emphasizes the important role of multidisciplinary teams in improving medication adherence, and discusses the importance of transplantation multidisciplinary teams and holistic management. By integrating the research results from various fields such as medicine, pharmacy, psychology, and sociology, it provides a more comprehensive theoretical support and practical guidance for improving medication adherence in heart transplant patients.

A qualitative, theory-based exploration of facilitators and barriers for implementation of pharmacist prescribing in chronic kidney disease

BACKGROUND

While there is an accumulation of evidence that pharmacist prescribing is safe and effective, there is a lack of research on processes of implementation into practice, particularly for patients with complex clinical conditions such as chronic kidney disease (CKD).

AIM

The aim was to explore the facilitators and barriers to the implementation of pharmacist prescribing for patients with CKD in the United Kingdom (UK).

METHOD

Semi-structured interviews were conducted with UK Renal Pharmacy Group members who were independent prescribers. The Consolidated Framework for Implementation Research (CFIR) underpinned the interview schedule. Interviews were recorded, transcribed, and independently coded by two researchers. A thematic approach was used for analysis, with data generation continuing until saturation of themes. Ethical approval was granted.

RESULTS

Data saturation was achieved following 14 interviews. Most interviewees were female (n = 11), all had secondary care as their main practice setting, and were highly experienced prescribers with 8 having 11 or more years of prescribing practice. Interviewees were positive regarding the development of their prescribing practice. Facilitators and barriers emerged across all 5 of the CFIR domains. Key facilitators were aspects of inner setting (e.g., organisational support and communication) while key barriers were also related to inner setting, specifically the need for adequate structural and financial resources.

CONCLUSION

This theory-based study has illuminated the facilitators and barriers for the implementation of pharmacist prescribing in CKD. There is a need to consider the resources required for implementation of prescribing practice at an early stage of planning and development.

Improving patient safety and access to healthcare: The role of pharmacist-managed clinics in optimizing therapeutic outcomes

Contemporary patient care requires a multidisciplinary approach to monitoring, assessing, and managing diseases. Promoting multidisciplinary approaches encourages the purposeful participation of many healthcare professionals and harnessing their combined knowledge to provide tailored treatment plans. Pharmacists, skilled and knowledgeable professionals in medication management, drug-related problems, and disease prevention, can offer vital interventions that contribute to improved patient outcomes. Advances in healthcare and information technology have expanded pharmacists' professional roles and made them essential in healthcare. Pharmacist-managed clinics (PMCs), an innovative healthcare approach, could potentially improve patient safety, satisfaction, accessibility, and affordability to quality healthcare. Spread across the healthcare continuum, pharmacists have a well-defined role in providing comprehensive pharmaceutical care and interprofessional collaboration, further reinforcing the necessity of establishing PMCs. This narrative review aims to compile and summarize information on PMCs from PubMed, Scopus, Web of Science, and Google Scholar till December 2023. The PMC shortlist covers specialties such as cardiovascular, hematologic, endocrine, pain medicine, respiratory medicine, infectious diseases, gastrointestinal, nephrology, neurology, and oncology. Pharmacists in disease-specific PMCs have demonstrated improved treatment outcomes and access to specialty care. Additionally, based on peer-reviewed literature, the review also highlights how PMCs enhance the pharmacist's role in improving disease-specific outcomes, overall quality of care, and medication management. The inclusion criteria are randomized controlled trials, case-control studies, cohort studies, and pre-post studies involving patients from cardiology, hematology, endocrinology, pain medicine, respiratory medicine, infectious diseases, neurology, nephrology, gastroenterology, and oncology specialties, focusing on pharmacist-driven clinics, published in English, and covering any geographical location. The exclusion criteria include review articles, proposed models, commentaries, editorials, and those published in languages other than English. Our findings reveal that PMCs are underutilized globally. PMCs work better in developed countries, possibly on account of robust healthcare infrastructure, adequate healthcare budgets, availability of trained pharmacists, and supportive regulatory environments. The review found that pharmacist-led interventions, such as medication monitoring and patient education, significantly enhance therapeutic outcomes. Pharmacist Managed Clinics improve affordability and acceptability, expanding healthcare access in outpatient and inpatient settings. This review also highlights the critical need for implementing PMCs to improve healthcare delivery, particularly in providing comprehensive and accessible services in developing countries.

2024 AAHA Community Care Guidelines for Small Animal Practice

Community care is a creative way of thinking about health care that mobilizes resources within a community and consists of four core principles: recognition of the urgency of access-to-care for the veterinary profession, collaboration within community networks, family-centered health care, and redefining the gold standard of care. The AAHA Community Care Guidelines for Small Animal Practice offer strategies to help busy veterinary practitioners increase access to care within their practice and community by optimizing collaborative networks. While these guidelines do not claim to provide exhaustive solutions to access-to-care issues, they propose a starting point from which private practices can explore and implement workable solutions for their community and their practice. Broadening the scope of care to reach all people with pets requires multimodal, collaborative, and creative solutions both within and outside of the veterinary profession. These solutions can begin with greater communication and collaboration between private veterinary practices and nonprofit veterinary practices, with the goal of keeping pets in their homes with their loving families as much as reasonably possible.

Improving Guideline-Directed Medical Therapy for Patients With Heart Failure With Reduced Ejection Fraction: A Review of Implementation Strategies

Despite recent advances in the use of guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), achievement of target GDMT use and up-titration to goal dosages continue to be modest. In recent years, a number of interventional approaches to improve the usage of GDMT have been published, but many are limited by single-center experiences with small sample sizes. However, strategies including the use of multidisciplinary teams, dedicated GDMT titration algorithms and clinician audits with feedback have shown promise. There remains a critical need for large, rigorous trials to assess the utility of differing interventions to improve the use and titration of GDMT in HFrEF. Here, we review existing literature in GDMT implementation for those with HFrEF and discuss future directions and considerations in the field.

Current status of outpatient heart failure management in Egypt and recommendations for the future

Heart failure (HF) represents one of the greatest healthcare burdens worldwide, and Egypt is no exception. HF healthcare programmes in Egypt still require further optimization to enhance diagnosis and management of the disease. Development of specialized HF clinics (HFCs) and their incorporation in the healthcare system is expected to reduce HF hospitalization and mortality rates and improve quality of care in Egypt. We conducted a literature search on PubMed on the requirements and essential infrastructure of HFCs. Retrieved articles deemed relevant were discussed by a panel of 10 expert cardiologists from Egypt and a basic HFC model for the Egyptian settings was proposed. A multidisciplinary team managing the HFC should essentially be composed of specialized HF cardiologists and nurses, clinical pharmacists, registered nutritionists, physiotherapists, and psychologists. Other clinical specialists should be included according to patients' needs and size and structure of individual clinics. HFCs should receive patients referred from primary care settings, emergency care units, and physicians from different specialties. A basic HFC should have the following fundamental investigations available: resting electrocardiogram, basic transthoracic echocardiogram, and testing for N-terminal pro-B-type natriuretic peptide. Fundamental patients' functional assessments are assessing the New York Heart Association functional classification and quality of life and conducting the 6 min walking test. guideline-directed medical therapy should be implemented, and device therapy should be utilized when available. In the first visit, once HF is diagnosed and co-morbidities assessed, guideline-directed medical therapy should be started immediately. Comprehensive patient education sessions should be delivered by HF nurses or clinical pharmacists. The follow-up visit should be scheduled during the initial visit rather than over the phone, and time from the initial visit to the first follow-up visit should be determined based on the patient's health status and needs. Home and virtual visits are only recommended in limited and emergency situations. In this paper, we provide a practical and detailed review on the essential components of HFCs and propose a preliminary model of HFCs as part of a comprehensive HF programme model in Egypt. We believe that other low-to-middle income countries could also benefit from our proposed model.

Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

Pharmacist- and Nurse-Led Medical Optimization in Heart Failure: A Systematic Review and Meta-Analysis

BACKGROUND

Traditional approaches to guideline-directed medical therapy (GDMT) management often lead to delayed initiation and titration of therapies in patients with heart failure. This study sought to characterize alternative models of care involving nonphysician provider-led GDMT interventions and their associations with therapy use and clinical outcomes.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing nonphysician provider-led GDMT initiation and/or uptitration interventions vs usual physician care (PROSPERO ID: CRD42022334661). We queried PubMed, Embase, the Cochrane Library, and the World Health Organization International Clinical Trial Registry Platform for peer-reviewed studies from database inception to July 31, 2022. In the meta-analysis, we used RCT data only and leveraged random-effects models to estimate pooled outcomes. Primary outcomes were GDMT initiation and titration to target dosages by therapeutic class. Secondary outcomes included all-cause mortality and HF hospitalizations.

RESULTS

We reviewed 33 studies, of which 17 (52%) were randomized controlled trials with median follow-ups of 6 months; 14 (82%) trials evaluated nurse interventions, and the remainder assessed pharmacists' interventions. The primary analysis pooled data from 16 RCTs, which enrolled 5268 patients. Pooled risk ratios (RR) for renin-angiotensin system inhibitor (RASI) and beta-blocker initiation were 2.09 (95% CI 1.05-4.16; I2 = 68%) and 1.91 (95% CI1.35-2.70; I2 = 37%), respectively. Outcomes were similar for uptitration of RASI (RR 1.99, 95% CI 1.24-3.20; I2 = 77%) and beta-blocker (RR 2.22, 95% CI 1.29-3.83; I2 = 66%). No association was found with mineralocorticoid receptor antagonist initiation (RR 1.01, 95% CI 0.47-2.19). There were lower rates of mortality (RR 0.82, 95% CI 0.67-1.04; I2 = 12%) and hospitalization due to HF (RR 0.80, 95% CI 0.63-1.01; I2 = 25%) across intervention arms, but these differences were small and not statistically significant. Prediction intervals were wide due to moderate-to-high heterogeneity across trial populations and interventions. Subgroup analyses by provider type did not show significant effect modification.

CONCLUSIONS

Pharmacist- and nurse-led interventions for GDMT initiation and/or uptitration improved guideline concordance. Further research evaluating newer therapies and titration strategies integrated with pharmacist- and/or nurse-based care may be valuable.

Optimising adherence to secondary prevention medications following acute coronary syndrome utilising telehealth cardiology pharmacist clinics: a matched cohort study

BACKGROUND

Adherence to secondary prevention medications following acute coronary syndromes (ACS) is a predictor of future major adverse cardiovascular events. Underutilisation of these medications is associated with higher risk of major adverse cardiovascular events globally.

AIM

To explore the effects of a telehealth cardiology pharmacist clinic on patient adherence to secondary prevention medications in the 12 months following ACS.

METHOD

Retrospective matched cohort study within a large regional health service comparing patient populations before and after implementation of pharmacist clinic with 12-month follow up. Patients who received percutaneous coronary intervention for ACS were consulted by the pharmacist at 1, 3- and 12-months. Matching criteria included age, sex, presence of left ventricular dysfunction and ACS type. Primary outcome was difference in adherence in adherence at 12 months post ACS. Secondary outcomes included major adverse cardiovascular events at 12 months and validation of self-reported adherence using medication possession ratios from pharmacy dispensing records.

RESULTS

There were 156 patients in this study (78 matched pairs). Analysis of adherence at 12 months demonstrated an absolute increase in adherence by 13% (31 vs. 44%, p = 0.038). Furthermore, sub-optimal medical therapy (less than 3 ACS medication groups at 12 months) reduced by 23% (31 vs. 8%, p = 0.004).

CONCLUSION

This novel intervention significantly improved adherence to secondary prevention medications at 12 months, a demonstrated contributor to clinical outcomes. Primary and secondary outcomes in the intervention group were both statistically significant. Pharmacist-led follow up improves adherence and patient outcomes.

Impact of Pharmacist-Led Heart Failure Clinic on Optimization of Guideline-Directed Medical Therapy (PHARM-HF)

This prospective study included patients with heart failure (HF) with reduced ejection fraction (HFrEF) with LVEF < = 40% to evaluate the impact of pharmacist on guideline directed medical therapy (GDMT). The primary outcome was to compare proportion of triple GDMT achieved for Angiotensin-Converting-Enzyme-Inhibitors (ACEI)/Angiotensin-Receptor-Blockers (ARB)/Angiotensin-Receptor-Neprilysin-Inhibitors (ARNI), beta-blockers, aldosterone antagonists (AA), and quadruple GDMT which in additional to triple therapy, included Sodium glucose co-transporter 2 inhibitor (SGLT2i) at 90-day post-enrollment compared to baseline. Secondary endpoints included achieving target and/or maximally tolerated ACEI/ARB/ARNI and beta-blockers combined and individually as well as SGLT2i and AA GDMT at 90-day post-enrollment compared to baseline. We also compared combined and individual HF-related hospitalization/emergency room (ER) visits 90 days pre-/post-enrollment. Of the total 974 patients screened, 80 patients seen at least once in the heart failure medication titration clinic (HMTC) were included in the analysis. Median (IQR) age was 71 (57-69) years with majority white male. There was a significant improvement in the proportion of patients who achieved quadruple GDMT (p = 0.001) and triple GDMT (p-value = 0.020) at 90-day post-enrollment compared to baseline. The secondary GDMT outcomes were also significantly increased at 90 days post-enrollment compared to baseline. Significant difference in mean as well as proportion of combined HF-related hospitalization/ER-visits was found 90 days pre-/post-enrollment (p = 0.047). Our study found that pharmacist's intervention increased the proportion of patients who achieved GDMT at 90 days.

Missed opportunities in medical therapy for patients with heart failure in an electronically-identified cohort

BACKGROUND

National registries reveal significant gaps in medical therapy for patients with heart failure and reduced ejection fraction (HFrEF), but may not accurately (or fully) characterize the population eligible for therapy.

OBJECTIVE

We developed an automated, electronic health record-based algorithm to identify HFrEF patients eligible for evidence-based therapy, and extracted treatment data to assess gaps in therapy in a large, diverse health system.

METHODS

In this cross-sectional study of all NYU Langone Health outpatients with EF ≤ 40% on echocardiogram and an outpatient visit from 3/1/2019 to 2/29/2020, we assessed prescription of the following therapies: beta-blocker (BB), angiotensin converting enzyme inhibitor (ACE-I)/angiotensin receptor blocker (ARB)/angiotensin receptor neprilysin inhibitor (ARNI), and mineralocorticoid receptor antagonist (MRA). Our algorithm accounted for contraindications such as medication allergy, bradycardia, hypotension, renal dysfunction, and hyperkalemia.

RESULTS

We electronically identified 2732 patients meeting inclusion criteria. Among those eligible for each medication class, 84.8% and 79.7% were appropriately prescribed BB and ACE-I/ARB/ARNI, respectively, while only 23.9% and 22.7% were appropriately prescribed MRA and ARNI, respectively. In adjusted models, younger age, cardiology visit and lower EF were associated with increased prescribing of medications. Private insurance and Medicaid were associated with increased prescribing of ARNI (OR = 1.40, 95% CI = 1.02-2.00; and OR = 1.70, 95% CI = 1.07-2.67).

CONCLUSIONS

We observed substantial shortfalls in prescribing of MRA and ARNI therapy to ambulatory HFrEF patients. Subspecialty care setting, and Medicaid insurance were associated with higher rates of ARNI prescribing. Further studies are warranted to prospectively evaluate provider- and policy-level interventions to improve prescribing of these evidence-based therapies.

Economic Impact of Ambulatory Clinical Pharmacists in an Advanced Heart Failure Clinic

BACKGROUND

Clinical pharmacists play pivotal roles in multidisciplinary heart failure (HF) teams through the management of HF pharmacotherapy, but no study has examined the economic impact of HF ambulatory clinical pharmacists in an advanced HF clinic.

OBJECTIVE

The objective of the study was to evaluate the economic impact of HF ambulatory clinical pharmacist interventions in an advanced HF clinic using a cost-benefit analysis.

METHODS

This prospective observational study detailed HF ambulatory clinical pharmacist interventions over 6 months in an advanced HF clinic in a single-center tertiary teaching hospital. The economic impact of the interventions was estimated based on the indirect cost savings with pharmacist interventions and direct cost savings recommendations. A cost-benefit analysis was performed to assess the cost of delivering the interventions compared with the benefits generated by clinical pharmacists. Results were reported as a benefit-cost ratio and net benefits.

RESULTS

HF ambulatory clinical pharmacists made a total of 2,361 provider-accepted interventions over 6 months. Overall, the 3 most common intervention types were medication reconciliation (28.7%), dose change (20.8%), and addition of medication (12.3%). Anticoagulation (21.2%) was the most common intervened class of medication, followed by sodium-glucose cotransporter-2 inhibitor (12.3%) and angiotensin receptor neprilysin inhibitor (9.2%). The total net benefits were $55,553.24 over 6 months and the benefit-cost ratio was 1.55.

CONCLUSION AND RELEVANCE

The addition of cardiology clinical pharmacists to an advanced HF clinic may be financially justified and cost-beneficial.

Harnessing the Potential of Primary Care Pharmacists to Improve Heart Failure Management

BACKGROUND

Improved utilization of guideline-directed medical therapy (GDMT) in the management of heart failure with reduced ejection fraction (HFrEF) can reduce mortality, reduce heart failure hospitalizations, and improve quality of life. Despite well-established clinical guidelines, these therapies remain significantly underprescribed. The goal of this intervention was to increase prescribing of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), and beta-blockers at ≥ 50% target doses.

METHODS

The study team identified key drivers to adequate dosing of GDMT: (1) frequent and reliable follow-up visits for titration opportunities, (2) identification of actionable patients for therapy initiation and titration, and (3) reduction in prescribing practice variability. The interventions were implemented at an outpatient clinical site and consisted of three main components: (1) establishing a pharmacist-led heart failure medication titration clinic, (2) creation of a standardized titration protocol, and (3) utilization of a patient dashboard to identify eligible patients.

RESULTS

For patients seen in the titration clinic, in 14 months, the mean dose per patient increased from 31.3% to 70.5% of target dose for ACEI/ARB/ARNI, and from 45.8% to 85.4% for beta-blockers. At this clinical site, the percentage of HFrEF patients receiving > 50% of targeted dose increased from 39.7% to 46.7% for ACEI/ARB/ARNI, and from 39.5% to 42.9% for beta-blockers. For ACEI/ARB/ARNI, use of target doses was 5.9% higher (95% confidence interval [CI] = 3.6%-8.3%, p < 0.0001) for the intervention site, 0.2% higher (95% CI = -2.2%-2.5%, p = 0.89) during the intervention period, and 10.4% higher (95% CI = 6.9%-13.9%, p < 0.0001) for the interaction (intervention site during the intervention time period). For beta-blockers, use of target doses was 1.0% higher (95% CI = -0.6%-2.6%, p = 0.20) for the intervention site, 0.8% lower (95% CI = -2.4%-0.8%, p = 0.29) for the intervention period, and 5.8% higher (95% CI = 3.5%-8.1%, p < 0.0001) for the interaction (intervention site during the intervention time period).

CONCLUSION

Through this project's interventions, the prescribing of ACEI/ARB/ARNI and beta-blocker therapy at ≥ 50% target doses for patients with HFrEF was increased. This study demonstrates the value of a multifaceted, team-based approach that integrates population-level interventions such as clinical dashboard management with a pharmacist-led heart failure medication titration clinic.

Clinical Pharmacist's Intervention to Improve Medication Titration for Heart Failure: First Experience from Sudan

Background

Medications known to improve outcomes in heart failure (HF) are either not prescribed or prescribed at sub-therapeutic doses. The addition of clinical pharmacists to the HF team positively impacts optimizing prognostic medications for a patient with HF with reduced ejection fraction (HFrEF).

Objective

To assess the intervention of the clinical pharmacist as part of the multidisciplinary (MD) team in up-titration to achieve target doses of key therapeutic agents for HFrEF.

Methods

This was a prospective one group pretest-posttest interventional study; a comparison of the target dose achievement of key therapeutic agents for HFrEF was performed before and after clinical pharmacist interventions.

Results

Out of 110 HFrEF patients, 57.3% were males, and the mean age of patients was 55.8 years (SD 12.6). Cardiomyopathy was the leading cause of HF. At baseline, 86% were on angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors (ACEIs/ARBs/ARNi) and 93.6% on beta blockers (BBs). At the end of study, the proportion of patients achieved the target dose was significantly increased (0 vs 77.4%, 6.8 vs 85.4%, and 0 vs 55.6%) for ACEIs, ARBs and ARNi, respectively, and (8.6% vs 66.1%; P = 0.001) for BBs. Moreover, the up-titration process was associated with significant improvement in most clinical as ejection fraction and New York Heart Association (NYHA) scale and laboratory characteristics.

Conclusion

As a part of the MD team in the outpatient HF clinic, the clinical pharmacists increased the percentage of HFrEF patients achieving the target or maximal doses of key therapeutic agents and improving clinical and laboratory parameters.

Evaluation of Quality of Care for US Veterans With Recent-Onset Heart Failure With Reduced Ejection Fraction

Importance

Multiple guideline-recommended therapies for heart failure with reduced ejection fraction (HFrEF) are available and promoted by performance measures. However, contemporary data on the use of these therapies are limited.

Objective

To evaluate trends in guideline-directed medical therapy, implantable cardioverter-defibrillator (ICD) use, and risk-adjusted mortality among patients with recent-onset HFrEF.

Design, Setting, and Participants

This cohort study analyzed claims and electronic health record data of patients with recent-onset HFrEF diagnosed at US Department of Veterans Affairs (VA) health care system facilities from July 1, 2013, through June 30, 2019. Veterans who had a history of heart transplant or used a ventricular assist device were among the patients who were excluded.

Exposures

Guideline-directed medical therapy (any β-blocker, guideline-recommended β-blocker [bisoprolol, carvedilol, or metoprolol succinate], angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, angiotensin receptor-neprilysin inhibitor, mineralocorticoid receptor antagonist, and hydralazine plus nitrate) and ICD.

Main Outcomes and Measures

Treatment rates for guideline-directed medical therapies and ICDs were calculated within 6 months of the index HFrEF date using medication fills, procedural codes for implantation and monitoring, and diagnosis codes. Risk-adjusted mortality was calculated after adjusting for baseline patient characteristics. For both treatment rates and risk-adjusted mortality, we evaluated the change over 3 periods (period 1: July 1, 2013, to June 30, 2015; period 2: July 1, 2015, to June 30, 2017; and period 3: July 1, 2017, to June 30, 2019) and variation across VA facilities.

Results

The final cohort comprised 144 074 eligible patients with incident HFrEF that was diagnosed between July 1, 2013, and June 30, 2019. The cohort had a mean (SD) age of 71.0 (11.4) years and was mostly composed of men (140 765 [97.7%]). Overall, changes in medical therapy rates were minimal over time, with the use of a guideline-recommended β-blocker increasing from 64.2% in 2013 to 72.0% in 2019. Rates for mineralocorticoid receptor antagonist therapy increased from 23.9% in 2013 to 26.9% in 2019, and rates for hydralazine plus nitrate therapy remained stable at 24.2% over the study period. Rates for angiotensin receptor-neprilysin inhibitor therapy increased since its introduction in 2015 but only to 22.6% in 2019. Among patients with an ICD indication, early use rates decreased over time. Substantial variation in medical therapy rates persisted across VA facilities. Risk-adjusted mortality decreased over the study period from 19.9% (95% CI, 19.6%-20.2%) in July 1, 2013, to June 30, 2015, to 18.4% (95% CI, 18.0%-18.7%) in July 1, 2017, to June 30, 2019 (OR, 0.96 per additional year; 95% CI, 0.96-0.97).

Conclusions and Relevance

This study found only marginal improvement between 2013 and 2019 in the guideline-recommended therapy and mortality rates among patients with recent-onset HFrEF. New approaches to increase the uptake of evidence-based HFrEF treatment are urgently needed and could lead to larger reductions in mortality.

Observing Interprofessional Collaboration: Impact on Attitude and Knowledge Acquisition

Interprofessional collaboration (IPC) in the medical field is an important factor for good clinical outcomes and should be taught as early as in undergraduate medical education. Since implementing IPC training is an organizational challenge, students are often limited in their opportunities to experience real-life IPC. Therefore, an approach where students observe successful IPC activities of role models in an applied anatomical format was proposed. It was studied whether observing IPC activities in undergraduate anatomical education has an impact on both students' attitude toward IPC and on knowledge acquisition. Further, it was examined whether the attitudes and knowledge of students from different medical disciplines were influenced in different ways. Therefore, 75 medical students and thirty-eight physiotherapy students participated in a study with the task of observing a live broadcast of an interprofessional teaching session. Participants were asked about their attitudes toward interprofessional learning, their evaluation of professional responsibilities, and their profession-specific knowledge before and after observing the IPC session. The participants' attitude toward interprofessional learning improved for both groups of students. Moreover, students of physiotherapy adjusted their evaluation of their own and others' professional responsibilities after observing IPC. In both student groups, knowledge increased, in particular, with respect to the field of knowledge in other professions. So, observing IPC can modify students' attitudes and support knowledge acquisition. The implementation of IPC observations provides students from various healthcare disciplines with a clearer impression of professionals' responsibilities and gives learners the opportunity to acquire knowledge from healthcare fields unfamiliar to them.

Care Gaps in Adherence to Heart Failure Guidelines: Clinical Inertia or Physiological Limitations?

OBJECTIVES

This study evaluated the impact of clinical and physiological factors limiting treatment optimization toward recommended medical therapy in heart failure (HF).

BACKGROUND

Although guidelines aim to assist physicians in prescribing evidence-based therapies and to improve outcomes of patients with HF and reduced ejection fraction (HFrEF), gaps in clinical care persist.

METHODS

Medical records of all patients with HFrEF followed for at least 6 months at the authors' HF clinic (n = 511) allowed for drug optimization and were reviewed regarding the prescription rates of recommended pharmacological agents and devices (implantable cardioverter-defibrillator [ICD] or cardiac resynchronization therapy [CRT]). Then, an algorithm integrating clinical (New York Heart Association [NYHA] functional class, heart rate, blood pressure and biologic parameters (creatinine, serum potassium) based on the inclusion/exclusion criteria of landmark trials guiding these recommendations) was applied for each agent and device to identify potential explanations for treatment gaps.

RESULTS

Gross prescription rates were high for beta-blockers (98.6%), mineralocorticoid receptor antagonist (MRA) (93.4%), vasodilators (90.3%), ICDs (75.1%), and CRT (82.1%) among those eligible, except for ivabradine (46.3%, n = 41). However, achievement of target physiological doses was lower (beta-blockers, 67.5%; MRA, 58.9%; and vasodilators, 63.4%), and one-fifth of patient dosages were still being up-titrated. Suboptimal doses were associated with older age (odds ratio [OR]: 1.221; p < 0.0001) and history of stroke or transient ischemic attack (TIA) (no vs. yes, OR: 0.264; p = 0.0336).

CONCLUSIONS

Gaps in adherence to guidelines exist in specialized HF setting and are mostly explained by limiting physiological factors rather than inertia. Older age and history of stroke/TIA, potential markers of frailty, are associated with suboptimal doses of guideline-directed medical therapy, suggesting that an individualized rather than a "one-size-fits-all" approach may be required.

Empowering People Living with Heart Failure

Heart failure is a chronic disease with a multitude of different clinical manifestations. Empowering people living with heart failure requires education, support structure, understanding the needs of patients, and reimaging the care delivery systems currently offered to patients. In this article, the authors discuss practical approaches to activate and empower people with heart failure and enable patient-provider dialogue and shared decision making.

Virani SA, Zieroth S, Bray S, Ducharme A, Harkness K, Koshman SL, McDonald M, O'Meara E, Swiggum E, Chan M, Ezekowitz JA, Giannetti N, Grzeslo A, Heckman GA, Howlett JG, Lepage S, Mielniczuk L, Moe GW, Toma M, Abrams H, Al-Hesaye A, Cohen-Solal A, D'Astous M, De S, Delgado D, Desplantie O, Estrella-Holder E, Green L, Haddad H, Hernandez AF, Kouz S, LeBlanc MH, Lee D, Masoudi FA, Matteau S, McKelvie R, Parent MC, Rajda M, Ross HJ, Sussex B. The Status of Specialized Ambulatory Heart Failure Care in Canada: A Joint Canadian Heart Failure Society and Canadian Cardiovascular Society Heart Failure Guidelines Survey

This joint Canadian Heart Failure Society and the CCS Heart Failure guidelines report has been developed to provide a pan-Canadian snapshot of the current state of clinic-based ambulatory heart failure (HF) care in Canada with specific reference to elements and processes of care associated with quality and high performing health systems. It includes the viewpoints of persons with lived experience, patient care providers, and administrators. It is imperative to build on the themes identified in this survey, through engaging all health care professionals, to develop integrated and shared care models that will allow better patient outcomes. Several patient and organizational barriers to care were identified in this survey, which must inform the development of regional care models and pragmatic solutions to improve transitions for this patient population. Unfortunately, we were unsuccessful in incorporating the perspectives of primary care providers and internal medicine specialists who provide the majority of HF care in Canada, which in turn limits our ability to comment on strategies for capacity building outside the HF clinic setting. These considerations must be taken into account when interpreting our findings. Engaging all HF care providers, to build on the themes identified in this survey, will be an important next step in developing integrated and shared care models known to improve patient outcomes.

Evaluating Pharmacist Impact on Guideline-Directed Medical Therapy in Patients With Reduced Ejection Fraction Heart Failure

BACKGROUND

Limited literature exists evaluating the ability of a pharmacist to quickly and effectively initiate and manage dose titrations of guideline-directed medication therapy (GDMT) in an outpatient setting.

METHODS

This pilot study aimed to investigate the impact of pharmacist-managed, outpatient heart failure management on patients' heart failure outcomes, and health-care-related costs. Retrospective chart review performed on patients referred to pharmacist practicing under collaborative practice agreement. End points included time to achieve individualized target doses of GDMT; beta-blocker dose tolerance; and the clinic's impact on left ventricular ejection fraction (LVEF), hospital admission, and emergency department encounter rates. Descriptive statistics were used to report nominal data. Wilcoxon signed-rank test was used to evaluate continuous variables.

RESULTS

Thirty-six patients completed full titration utilizing an average of 4.9 visits over 12.7 weeks. Seventy-eight percent (n = 28) achieved full beta-blocker titration. Seventy-six percent of patients had LVEF >35% after titration versus 43% at baseline. A significant reduction in all-cause hospital admissions was seen during both 13-week and 12-month comparison periods (P < .05). We estimated >US$50 000 annual revenue generation from 0.2 full-time equivalent pharmacist.

CONCLUSIONS

Although hypothesis generating, our results support the idea that pharmacist-managed medication titration clinics are effective at completing titration, improving LVEF, and generating revenue.

Effectiveness and safety of physician–pharmacist collaborative care for rheumatoid arthritis patients: The Changi General Hospital’s experience

Background:

Increasing demand for follow-up of rheumatoid arthritis has encouraged pharmacists to collaborate with physicians to assist with patient care.

Objective:

The aim of this study was to assess the effectiveness and safety of the collaborative care model in a rheumatoid arthritis clinic.

Methods:

We performed a retrospective review of patient case notes and medication records from March 2013 to February 2016. The effectiveness and safety of collaborative care was examined in pre-implementation (standard care) versus post-implementation (collaborative care) cohorts. All patients were assessed for 12 months. Effectiveness of clinic was measured using the percentage of patients that achieved optimal doses of non-biologic disease-modifying anti-rheumatic drugs (nb-DMARDs). Clinic safety performance was evaluated based on the percentage of patients in each cohort that achieved compliance to in-house hospital guidelines on nb-DMARD monitoring. Other clinic safety factors monitored included the incidence and characteristics of nb-DMARD-associated adverse drug events.

Results:

Thirty-eight patients who had received standard care and collaborative care were reviewed. More patients receiving collaborative care achieved nb-DMARD dose optimization within a year of initiation of therapy (68.4% vs 39.5%; p-value < 0.05). Compliance to safety recommendations from hospital guidelines on nb-DMARD monitoring was significantly higher in the collaborative care group (70.6% vs 44.1%; p-value < 0.05). Collaborative care resulted in a higher incidence of nb-DMARD-associated adverse drug events being detected (26.3% vs 18.4%; p-value < 0.05). The most common adverse drug events were gastrointestinal (29.4%), dermatological (17.6%), and hematologic (17.6%), the majority being mild in severity.

Conclusion:

Collaborative rheumatoid arthritis care contributed to improvements in nb-DMARD dose optimization, compliance to hospital guidelines on monitoring, and the detection of nb-DMARD-related adverse drug events.

A Scoping Review of the Quality and the Design of Evaluations of Mobile Health, Telehealth, Smart Pump and Monitoring Technologies Performed in a Pharmacy-Related Setting

Background: There is currently a need for high quality evaluations of new mobile health, telehealth, smart pump and monitoring technologies undertaken in a pharmacy-related setting. We aim to evaluate the use of these monitoring technologies performed in this setting. Methods: A systematic searching of English articles that examined the quality and the design of technologies conducted in pharmacy-related facilities was performed using the following databases: MEDLINE and Cumulative index to Nursing and Allied Health Literature (CINAHL) to identify original studies examining the quality and the design of technologies and published in peer-reviewed journals. Extraction of articles and quality assessment of included articles were performed independently by two authors. Quality scores over 75% are classed as being acceptable using a "relatively conservative" quality benchmark. Scores over 55% are included using a "relatively liberal" cut-off point. Results: Screening resulted in the selection of 40 formal evaluations. A substantial number of studies (32, 80.00%) were performed in the United States, quantitative in approach (33, 82.50%) and retrospective cohort (24, 60.00%) in study design. The most common pharmacy-related settings were: 22 primary care (55.00%); 10 hospital pharmacy (25.00%); 7 community pharmacy (17.50%); one primary care and hospital pharmacy (2.50%). The majority of the evaluations (33, 82.50%) reported clinical outcomes, six (15.00%) measured clinical and economic outcomes, and one (2.50%) economic only. Twelve (30.00%) quantitative studies and no qualitative study met objective criteria for "relatively conservative" quality. Using a lower "relatively liberal" benchmark, 27 quantitative (81.82%) and four qualitative (57.41%) studies met the lower quality criterion. Conclusion: Worldwide, few evaluations of mobile health, telehealth, smart pump and monitoring technologies in pharmacy-related setting have been published.Their quality is often below the standard necessary for inclusion in a systematic review mainly due to inadequate study design.

Implementation and Preliminary Clinical Outcomes of a Pharmacist-managed Venous Thromboembolism Clinic for Patients Treated With Rivaroxaban Post Emergency Department Discharge

OBJECTIVE

The objective was to describe the implementation, work flow, and differences in outcomes between a pharmacist-managed clinic for the outpatient treatment of venous thromboembolism (VTE) using a non-vitamin K oral anticoagulant versus care by a primary care provider (PCP).

METHODS

Patients in the studied health system that are diagnosed with low-risk VTE in the emergency department are often discharged without hospital admission. These patients are treated with a non-vitamin K oral anticoagulant and follow-up either in a pharmacist-managed VTE clinic or with their PCP. Pharmacists in the VTE clinic work independently under a collaborative practice agreement (CPA). An evaluation of 34 patients, 17 in each treatment arm, was conducted to compare the differences in treatment-related outcomes of rivaroxaban when managed by a pharmacist versus a PCP.

RESULTS

The primary endpoint was a 6-month composite of anticoagulation treatment-related complications that included a diagnosis of major bleeding, recurrent thromboembolism, or fatality due to either major bleeding or recurrent thromboembolism. Secondary endpoints included number of hospitalizations, adverse events, and medication adherence. There was no difference in the primary endpoint between groups with one occurrence of the composite endpoint in each treatment arm (p = 1.000), both of which were recurrent thromboembolic events. Medication adherence assessment was formally performed in eight patients in the pharmacist group versus no patients in the control group. No differences were seen among other secondary endpoints.

CONCLUSIONS

The pharmacist-managed clinic is a novel expansion of clinical pharmacy services that treats patients with low-risk VTEs with rivaroxaban in the outpatient setting. The evaluation of outcomes provides support that pharmacist-managed care utilizing standardized protocols under a CPA may be as safe as care by a PCP.

Impact of Pharmacy Student-Driven Postdischarge Telephone Calls on Heart Failure Hospital Readmission Rates: A Pilot Program

Background: Heart failure (HF) hospitalization rates have remained high in the past 10 years. Numerous studies have shown significant improvement in HF readmission rates when pharmacists or pharmacy residents conduct postdischarge telephone calls. Objective: The purpose of this retrospective review of a pilot program was to evaluate the impact of pharmacy student-driven postdischarge phone calls on 30- and 90-day hospital readmission rates in patients recently discharged with HF. Methods: A retrospective manual chart review was conducted for all patients who received a telephone call from the pharmacy students. The primary endpoint compared historical readmissions, 30 and 90 days prior to hospital discharge, with 30 and 90 days post discharge readmissions. For the secondary endpoints, historical and postdischarge 30-day and 90-day readmission rates were compared for patients with a primary diagnosis of HF and for patients with a secondary diagnosis of HF. Descriptive statistics were calculated in the form of means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Results: Statistically significant decrease was observed for both the 30-day (P = .006) and 90-day (P = .007) readmission periods. Prior to the pharmacy students' phone calls, the overall group of 131 patients had historical readmission rates of 24.43% within 30 days and 38.17% within 90 days after hospital discharge. After the postdischarge phone calls, the readmission rates decreased to 11.45%, for 30 days, and 22.90%, for 90 days. Conclusion: Postdischarge phone calls, specifically made by pharmacy students, demonstrated a positive impact on reducing HF-associated hospital readmissions, adding to the growing body of evidence of different methods of pharmacy interventions and highlighting the clinical impact pharmacy students may have in transition of care services.

Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review

BACKGROUND

The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success.

METHODS

We searched databases from January 1990 to November 2017 for studies testing interventions to improve uptake of class I HF guidelines. We used the Cochrane Effective Practice and Organisation of Care and Process Redesign frameworks for data extraction. Primary outcomes included: proportion of eligible patients offered guideline-recommended pharmacotherapy, self-care education, left ventricular function assessment and/or intracardiac devices. We reported clinical outcomes when available.

RESULTS

We included 38 studies. Provider-level interventions (n=13 studies) included audit and feedback, reminders and education. Organisation-level interventions (n=18) included medical records system changes, multidisciplinary teams, clinical pathways and continuity of care. System-level interventions (n=3) included provider/institutional incentives. Four studies assessed multi-level interventions. We could not perform meta-analyses due to statistical/conceptual heterogeneity. Thirty-two studies reported significant improvements in at least one primary outcome. Clinical pathways, multidisciplinary teams and multifaceted interventions were most consistently successful in increasing physician uptake of guidelines. Among randomised controlled trials (RCT) (n=10), pharmacist and nurse-led interventions improved target dose prescriptions. Eleven studies reported clinical outcomes; significant improvements were reported in three, including a clinical pathway, a multidisciplinary team and a multifaceted intervention. Baseline assessment of barriers, staff training, iterative intervention development, leadership commitment and policy/financial incentives were associated with intervention effectiveness. Most studies (n=20) had medium risk of bias; nine RCTs had low risk of bias.

CONCLUSION

Our study is limited by the quality and heterogeneity of the primary studies. Clinical pathways, multidisciplinary teams and multifaceted interventions appear to be most consistent in increasing guideline uptake. However, improvements in process outcomes were rarely accompanied by improvements in clinical outcomes. Our work highlights the need for improved research methodology to reliably assess the effectiveness of implementation interventions.

A Review of the Role of the Pharmacist in Heart Failure Transition of Care

This article reviews current literature on the role of pharmacists in the transition of care (TOC) for patients with heart failure (HF) and the impact of their contributions on therapeutic and economic outcomes. Optimizing the TOC for patients with HF from the hospital to the community/home is crucial for improving outcomes and decreasing high rates of hospital readmissions, which are associated with increased morbidity, mortality, and costs. A multidisciplinary team approach to the management of patients with HF facilitates the transition from the hospital to the ambulatory care setting, allowing for the consideration of medical, pharmacological, and lifestyle variables that impact the care of individual patients. Pharmacist participation on both inpatient and outpatient teams can provide a variety of services that have been shown to reduce hospital readmission rates and benefit patient management and treatment. These include medication reconciliation, patient education, medication dosage titration and adjustment, patient monitoring, development of disease management pathways, promotion of medication adherence, and postdischarge follow-up. In addition, as new pharmacologic treatments for HF become available, pharmacists can raise awareness of optimal drug use by maximizing education related to efficacy (e.g., adherence) and safety (e.g., potential side effects and drug interactions). Improving understanding of HF and its treatment will enable increased pharmacist involvement in the TOC that should lead to improved outcomes and reduced healthcare costs.

FUNDING

Novartis.

Outcomes of a Pharmacist-Managed Heart Failure Medication Titration Assistance Clinic

Background: National guidelines recommend angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) and β-blockers (BBs) at target doses for morbidity and mortality benefits in heart failure with reduced ejection fraction (HFrEF); regardless, titration of these therapies in practice remains suboptimal. We implemented an outpatient pharmacist-managed HFrEF medication titration assistance clinic (MTAC) at one institution to improve titration for general cardiology (GC) patients. Objective: To evaluate MTAC impact by determining the proportion of patients on target or maximum tolerated ACE inhibitor/ARB and BB doses. Methods: A retrospective chart review of adult patients with documented ejection fraction ≤40% managed in the MTAC or GC from 2011 to 2013 was conducted. HFrEF medication regimens were collected at initial visit and months 1, 2, 3, 6, 9, and 12 to assess titration. Target doses were defined per guideline or dose at which ejection fraction recovered during the study. Maximum tolerated doses were defined as the highest dose patients tolerated without physiological limitations. Results: Of 148 patients, the MTAC managed 51 and GC managed 97. At baseline, 90% of MTAC versus 82% of GC patients were prescribed ACE inhibitors/ARBs and BBs. In the MTAC, 4% were at target or maximum tolerated doses compared with 32% of GC patients ( P < 0.001). At 12 months, 95% of patients in the MTAC and 87% in GC were prescribed ACE inhibitors/ARBs and BBs. Of those prescribed ACE inhibitors/ARBs and BBs, 64% in the MTAC versus 40% in GC reached target or maximum tolerated doses ( P = 0.01). Conclusions: The pharmacist-managed MTAC increased the proportion of patients on optimal HFrEF therapies and are a resource for GC patients.

Treatment Considerations and the Role of the Clinical Pharmacist Throughout Transitions of Care for Patients With Acute Heart Failure

Heart failure is associated with increased risk of morbidity and mortality, resulting in substantial health-care costs. Clinical pharmacists have an opportunity to reduce health-care costs and improve disease management as patients transition from inpatient to outpatient care by leading interventions to develop patient care plans, educate patients and clinicians, prevent adverse drug reactions, reconcile medications, monitor drug levels, and improve medication access and adherence. Through these methods, clinical pharmacists are able to reduce rates of hospitalization, readmission, and mortality. In addition, care by clinical pharmacists can improve dosing levels and adherence to guideline-directed therapies. A greater benefit in patient management occurs when clinical pharmacists collaborate with other members of the health-care team, emphasizing the importance of heart failure treatment by a multidisciplinary health-care team. Education is a key area in which clinical pharmacists can improve care of patients with heart failure and should not be limited to patients. Clinical pharmacists should provide education to all members of the health-care team and introduce them to new therapies that may further improve the management of heart failure. The objective of this review is to detail the numerous opportunities that clinical pharmacists have to improve the management of heart failure and reduce health-care costs as part of a multidisciplinary health-care team.

Patient-oriented education and medication management intervention for people with decompensated cirrhosis: study protocol for a randomized controlled trial

BACKGROUND

People with decompensated cirrhosis require complex medical care and are often prescribed an intricate and frequently changing medication and lifestyle regimen. However, many patients mismanage their medications or have poor comprehension of their disease and self-management tasks. This can lead to harm, hospitalization, and death.

METHODS/DESIGN

A patient-oriented education and medication management intervention has been developed for implementation at a tertiary hospital hepatology outpatient center in Queensland, Australia. Consenting patients with decompensated cirrhosis will be randomly allocated to education intervention or usual care treatment arms when they attend routine follow-up appointments. In the usual care arm, participants will be reviewed by their hepatologist according to the current model of care in the hepatology clinic. In the intervention arm, participants will be reviewed by a clinical pharmacist to receive the education and medication management intervention at baseline in addition to review by their hepatologist. Intervention participants will also receive three further educational contacts from the clinical pharmacist within the following 6-month period, in addition to routine hepatologist review that is scheduled within this time frame. All participants will be surveyed at baseline and follow-up (approximately 6 months post-enrollment). Validated questionnaire tools will be used to determine participant adherence, medication beliefs, illness perceptions, and quality of life. Patients' knowledge of dietary and lifestyle modifications, their current medications, and other clinical data will be obtained from the survey, patient interview, and medical records. Patient outcome data will be collected at 52 weeks.

DISCUSSION

The intervention described within this protocol is ready to adapt and implement in hepatology ambulatory care centers globally. Investigation of potentially modifiable variables that may impact medication management, in addition to the effect of a clinical pharmacist-driven education and medication management intervention on modifying these variables, will provide valuable information for future management of these patients.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry identifier: ACTRN12616000780459 . Registered on 15 June 2016.

Risk factors of adverse health outcomes after hospital discharge modifiable by clinical pharmacist interventions: a review with a systematic approach

The present review assessed the evidence on risk factors for the occurrence of adverse health outcomes after discharge (i.e. unplanned readmission or adverse drug event after discharge) that are potentially modifiable by clinical pharmacist interventions. The findings were compared with patient characteristics reported in guidelines that supposedly indicate a high risk of drug-related problems. First, guidelines and risk assessment tools were searched for patient characteristics indicating a high risk of drug-related problems. Second, a systematic PubMed search was conducted to identify risk factors significantly associated with adverse health outcomes after discharge that are potentially modifiable by a clinical pharmacist intervention. After the PubMed search, 37 studies were included, reporting 16 risk factors. Only seven of 34 patient characteristics mentioned in pertinent guidelines corresponded to one of these risk factors. Diabetes mellitus (n = 11), chronic obstructive lung disease (n = 9), obesity (n = 7), smoking (n = 5) and polypharmacy (n = 5) were the risk factors reported most frequently in the studies. Additionally, single studies also found associations of adverse health outcomes with different drug classes {e.g. warfarin [hazard ratio 1.50; odds ratio (OR) 3.52], furosemide [OR 2.25] or high beta-blocker starting doses [OR 3.10]}. Although several modifiable risk factors were found, many patient characteristics supposedly indicating a high risk of drug-related problems were not part of the assessed risk factors in the context of an increased risk of adverse health outcomes after discharge. Therefore, an obligatory set of modifiable patient characteristics should be created and implemented in future studies investigating the risk for adverse health outcomes after discharge.

Impact of a Pharmacist-Managed Heart Failure Postdischarge (Bridge) Clinic for Veterans

Background: Hospitals that provide early postdischarge follow-up after heart failure (HF) hospitalization tend to have lower rates of readmission. However, HF postdischarge (bridge) clinics have not been extensively evaluated. Objective: To assess the impact of a pharmacist-managed HF bridge clinic in a veteran population. Methods: HF patients hospitalized from November 2010 to August 2013 were identified. Retrospective chart review was conducted of 122 HF patients seen at bridge clinic compared with 122 randomly selected HF patients not seen at this clinic (usual care). Primary end point was 90-day all-cause readmission and death. Secondary outcomes were 30-day all-cause readmission and death, time to first postdischarge follow-up, first all-cause readmission. Results: Bridge clinic patients were at higher baseline risk of readmission and death; other characteristics were similar. 90-day death and all-cause readmission trended lower in bridge clinic patients (adjusted hazard ratio [HR] = 0.64; 95% CI = 0.40-1.02; P = 0.06). Time to first follow-up was shorter in bridge clinic patients (11 ± 6 vs 20 ± 23 days; P < 0.001); time to first all-cause readmission trended longer (40 ± 20 vs 33 ± 25days; P = 0.11). 30-day death and all-cause readmission was significantly lower in bridge clinic patients (adjusted HR = 0.44; 95% CI = 0.22-0.88; P = 0.02). Conclusions: In veteran patients hospitalized for HF, pharmacist-managed HF bridge clinic significantly reduced the time to initial follow-up compared with usual care. Improved short-term outcomes and trend toward improvement of longer-term outcomes in bridge clinic patients was shown.

Expert Comment: Is Medication Titration in Heart Failure too Complex?

Large-scale randomised controlled trials (RCTs) have demonstrated that angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and beta-blockers decrease mortality and hospitalisation in patients with heart failure (HF) associated with a reduced left ventricular ejection fraction. This has led to high prescription rates; however, these drugs are generally prescribed at much lower doses than the doses achieved in the RCTs. A number of strategies have been evaluated to improve medication titration in HF, including forced medication up-titration protocols, point-of-care decision support and extended scope of clinical practice for nurses and pharmacists. Most successful strategies have been multifaceted and have adapted existing multidisciplinary models of care. Furthermore, given the central role of general practitioners in long-term monitoring and care coordination in HF patients, these strategies should engage with primary care to facilitate the transition between the acute and primary healthcare sectors.

Health Care Professionals' Opinions and Expectations of Clinical Pharmacy Services on a Surgical Ward

BACKGROUND

Pharmacists have made significant contributions to patient care and have been recognized as integral members of the interprofessional team. Health care professionals differ in their opinions and expectations of clinical pharmacy services. Very little has been published about health care professionals' perspectives on advanced clinical pharmacy roles, such as prescriptive authority or administration of vaccines. In 2013, clinical pharmacy services were introduced in a vascular and general surgery ward where a pharmacist had not previously been assigned.

OBJECTIVES

To explore surgical nurses' and physicians' opinions and expectations of clinical pharmacy services and to determine how these views changed over time; to compare pharmacists' views of clinical pharmacy services with those of nurses and physicians; and to develop validated survey tools.

METHODS

Three survey tools were created and validated, one for each profession. Surveys were distributed to nurses and physicians assigned to the general and vascular surgery ward before introduction of clinical pharmacy services and 8 months after implementation. Hospital pharmacists were invited to complete the survey at one time point.

RESULTS

Differences existed in the opinions of nurses, physicians, and pharmacists about some traditional activities. Nurses and physicians indicated stronger agreement with pharmacists participating in medication reconciliation activities than did pharmacists (p < 0.001), whereas a greater proportion of pharmacists felt that they were the most appropriate health care professionals to provide medication discharge counselling, relative to nurses and physicians (p = 0.001). Respondents supported advanced roles for pharmacists, such as collaborative practice agreements, but there was less support for prescribing, physical assessments, and administration of vaccines. Nurses indicated the strongest agreement with pharmacist prescribing (82% versus 69% among pharmacists and 27% among physicians; p < 0.001). Nurses and physicians expressed strong endorsements of clinical pharmacy services in the surveys' comment sections.

CONCLUSIONS

The introduction of clinical pharmacy services to a surgical health care team resulted in high levels of satisfaction among nurses and physicians who responded to this survey. Differences in perceptions of traditional clinical pharmacy service activities and advanced practice roles need to be studied in more depth to better understand the factors influencing health care professionals' views.

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.