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

Slade J, Lee M, Park J, Liu A, Heidenreich P, Allaudeen N. Harnessing the Potential of Primary Care Pharmacists to Improve Heart Failure Management. Joint Commission Journal on Quality and Patient Safety. 2022 Jan 1; 48(1):25-32.

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Abstract:

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.