Impact of a Pharmacist-led Cardiology Pharmacotherapy Clinic on Chronic Heart Failure Management

摘要

IntroductionThere are limited data on the impact of pharmacist-led heart failure (HF) clinics on care processes and outcomes. We compared the impact of pharmacist interventions in a cardiology pharmacotherapy clinic (CPC) versus standard care in general cardiology and HF subspecialty clinics on medication titration and non-fatal HF events in patients with HF with reduced ejection fraction (HFrEF) at the Veterans Affairs Ann Arbor Healthcare System (VAAAHS). HypothesisPatients referred to CPC will be more likely to achieve target doses of guideline-recommended therapies and have fewer non-fatal HF events when compared to general cardiology. MethodsThis was a single-center retrospective chart review conducted at the VAAAHS in HFrEF patients (New York Heart Association Class II-IV) enrolled in general cardiology, HF subspecialty clinic, or CPC from July 1, 2009 to September 7, 2016. Exclusion criteria included terminal illness, dementia, investigational drug use, nursing home resident, and hospitalization in last month. The primary outcome was the proportion of patients on goal dose guideline-recommended therapies after 1 year of follow-up. Other outcomes included non-fatal HF events, defined as ER visits and hospital admissions for HF. Between-group differences were evaluated by t-testing or chi-square, and pre-post differences by McNemar's test. ResultsA total of 240 patients were evaluated and followed for 1 year. Patients in the CPC had an intermediate risk profile between general cardiology and HF subspecialty clinics. Patients referred to CPC were similarly likely to be on goal doses of ACEI/valsartan (ACE/ARB), evidence-based beta blockers (carvedilol/metoprolol succinate/bisoprolol; BB), and mineralocorticoid antagonists (MRA) as general cardiology, and less likely to be on target dose at baseline when compared to the HF subspecialty clinic. Between referral and 1 year of follow-up, the proportion of patients on goal-dose ACE/ARB (p = 0.02) and BB (p < 0.001) significantly increased in the CPC, but not in general cardiology or the HF subspecialty program. At one year, significantly more CPC patients were on target doses of BB and MRA compared to general cardiology (). There were slightly more ER visits in CPC patients, but no between-clinic differences in hospital admissions. ConclusionsPatients with HFrEF referred to a pharmacist-led clinic had more effective titration of evidence-based medications than through usual care in general cardiology.