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Integration of Clinical Pharmacists into a Heart Failure Clinic within a Safety-Net Hospital

Open AccessPublished:November 13, 2021DOI:https://doi.org/10.1016/j.japh.2021.11.012
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      Background

      Management of heart failure with reduced ejection fraction (HFrEF) requires timely initiation and up-titration of guideline-directed medical therapy (GDMT). In safety-net hospitals (SNHs), limited healthcare staff and resources make achievement of optimal medical therapy challenging. Recent studies have shown that medication titration performed by clinical pharmacists can improve outcomes in ambulatory management of HFrEF; however, the impact of these services within a SNH remains unknown.

      Objective

      Determine the impact of integrating clinical pharmacists into a heart failure (HF) clinic on initiation and titration of GDMT within a SNH.

      Methods

      We performed a single-center retrospective cohort study of patients with HFrEF treated in an ambulatory HF medication titration clinic within a SNH before and after clinical pharmacist integration. Primary outcomes included dose optimization rates of GDMT, time between clinic visits, and time to optimization of GDMT. Exploratory secondary outcomes were all-cause, HF, and cardiovascular acute care service utilization and all-cause, HF, and cardiovascular mortality before and after clinical pharmacist integration up to 6 months following initial clinic visit.

      Results

      A total of 153 patients with HFrEF were treated. Baseline characteristics in the pre- and post-intervention groups were comparable. After clinical pharmacist integration, there was a significant improvement in optimization of renin-angiotensin-aldosterone system inhibitor or hydralazine/nitrate equivalent (82% versus 94%, p=.02). Dose optimization rates of beta-blockers (90% versus 83%, p=0.22) and mineralocorticoid receptor antagonists (57% versus 57%, p>0.99) were unchanged. There was a significant reduction in mean time between clinic visits (26 versus 14 days, p < .0001), and in mean time to optimization of GDMT (88 versus 45 days, p=.0015). All-cause mortality was reduced (13% versus 2%, p=.01).

      Conclusion

      In SNHs, where limited healthcare staff and resources present as barriers to timely initiation and titration of GDMT, integration of clinical pharmacists into HF clinics can serve as a practical solution.

      Key Words

      Abbreviations:

      ACCF/AHA (American College of Cardiology Foundation/American Heart Association), BB (beta-blockers), EMR (electronic medical record), GDMT (guideline-directed medical therapy), HF (heart failure), HFrEF (heart failure with reduced ejection fraction), MRA (mineralocorticoid receptor antagonists), NP (nurse practitioners), NYHA (New York Heart Association), RAAS-I (renin-angiotensin-aldosterone system inhibitors), SCr (serum creatinine), SNH (safety-net hospital), TDD (total daily dose)