Clinical Pharmacy Services in Heart Failure: An Opinion Paper From the Heart Failure Society of America and American College of Clinical Pharmacy Cardiology Practice and Research Network

BackgroundHeart failure (HF) care takes place in multiple settings, with a variety of providers, and generally involves patients who have multiple comorbidities. This situation is a “perfect storm” of factors that predispose patients to medication errors.Methods and ResultsThe goals of this paper are to outline potential roles for clinical pharmacists in a multidisciplinary HF team, to document outcomes associated with interventions by clinical pharmacists, to recommend minimum training for clinical pharmacists engaged in HF care, and to suggest financial strategies to support clinical pharmacy services within a multidisciplinary team. As patients transition from inpatient to outpatient settings and between multiple caregivers, pharmacists can positively affect medication reconciliation and education, assure consistency in management that results in improvements in patient satisfaction and medication adherence, and reduce medication errors. For mechanical circulatory support and heart transplant teams, the Centers for Medicare and Medicaid Services considers the participation of a transplant pharmacology expert (e.g., clinical pharmacist) to be a requirement for accreditation, given the highly specialized and complex drug regimens used. Although reports of outcomes from pharmacist interventions have been mixed owing to differences in study design, benefits such as increased use of evidence-based therapies, decreases in HF hospitalizations and emergency department visits, and decreases in all-cause readmissions have been demonstrated. Clinical pharmacists participating in HF or heart transplant teams should have completed specialized postdoctoral training in the form of residencies and/or fellowships in cardiovascular and/or transplant pharmacotherapy, and board certification is recommended. Financial mechanisms to support pharmacist participation in the HF teams are variable.ConclusionsPositive outcomes associated with clinical pharmacist activities support the value of making this resource available to HF teams.     

Assessment of clinical pharmacist interventions in drug therapy in patients with diabetes mellitus in a tertiary care teaching hospital

AimTo assess the impact of clinical pharmacist interventions in drug therapy in hospitalized patients with diabetes mellitus.MethodsA Prospective interventional study was carried out in the medicine wards of a tertiary care teaching hospital over a period of 10 months from September 2013 to June 2014. The drug therapy details of the patients were collected from inpatient case records in the respective clinical wards. Clinical pharmacist reviewed the drug therapy, identified the drug related problems during ward rounds and discussed with the physicians and suitable suggestions was provided which had been documented.ResultsA total of 189 drug therapy problems were identified from 151 patient case records. The number of drug related problems was found to more in males than females. Drug related problems were commonly seen in patients aged between 61 and 70 years of age. The most common drug related problems was found to be drug use without indication (17.98%) followed by improper drug selection (16.40%). The most frequent suggestions by the clinical pharmacist were on cessation of drug (30.68%). The acceptance rate of suggestions and the changes in drug therapy was found to be high (58.20%). The majority of the level of significance of drug related problems was seen to have moderate significance in grade.ConclusionInvolvement of clinical pharmacist as a member of healthcare team during ward rounds in hospitalized patients with diabetes mellitus helps in identification and prevention of drug related problems which will helps to rationalize drug therapy, achieve better therapeutic outcomes and improved patient care.     

Evaluation of clinical pharmacist mediated education and counselling of systemic lupus erythematosus patients in tertiary care hospital

ObjectivesTo assess the knowledge of systemic lupus erythematosus (SLE) patients before and after clinical pharmacist's education and compare the same with the control group.MethodsIn this study done on patients with SLE, the test group patients were provided with education regarding SLE and its management including lifestyle modifications, via the distribution of patient information leaflets (PILs), while the control group were continued with conventional therapy. Validated knowledge assessment questionnaire was administered at baseline, first follow-up and final (second) follow-up to assess the medication knowledge of SLE patients. The Modified Morisky Scale (MMS) was used to assess the adherence at the final follow-up to study the influence of education.ResultsForty-five patients completed the 2 months follow-up study out of 50 enrolled patients. A significant (P < 0.001) improvement in the medication knowledge scores and medication adherence was seen in test group compared to the control group. The reasons for non-compliance included patients forgetfulness, high cost of medications, patients lack of access to hospital/drug store, lack of family support/motivation, fear of side effects, and fear of becoming dependent on treatment.ConclusionThe finding of this study showed that a well-structured SLE patient counselling by clinical pharmacist's intervention will result in improved medication knowledge and better medication adherence.     

Potential benefits of warfarin monitoring by a clinical pharmacist in a long term care facility

The primary objective of this study was to determine whether warfarin therapy monitoring by a pharmacist would benefit a long-term care facility, by maintaining patients within therapeutic INR range more consistently than the current practice of physician monitoring.Secondary objectives included whether adverse events resulting from non-therapeutic INR levels differed significantly between groups and whether pharmacist interventions resulted in decreased overall costs to the facility. A retrospective chart review was conducted on all patients treated with warfarin for a minimum of 14 days within a Long-Term Care (LTC) facility to compare Time within Therapeutic Range (TTR) between staff treated patients versus pharmacist treated patients. A total of 552 INRs were obtained for all patients during the study period: 499 (90.4%) under staff supervision and 53 (9.6%) under clinical pharmacist supervision. Of the 499 tests performed by the River Garden staff, 203 were within the desired range, compared with 29 of the 53 tests performed by the clinical pharmacist being in range. For the primary endpoint, a total of 1483 INRs were imputed, corresponding to the number of days between true INR measurements. INRs attributable to clinic staff management were within the therapeutic range 47.1% of the time, whereas INRs attributable to clinical pharmacist management were within the therapeutic range 58.7% of the time (P < 0.0001 for the comparison). Warfarin can be effectively monitored by a clinical pharmacist and routinely lead to appropriate INR levels in the nursing home setting, while potentially saving the facility healthcare dollars.     

Optimizing Prophylactic Antibiotic Practice for Cardiothoracic Surgery by Pharmacists’ Effects

Pharmacists’ role may be ideal for improving rationality of drug prescribing practice. We aimed to study the impact of multifaceted pharmacist interventions on antibiotic prophylaxis in patients undergoing clean or clean-contaminated operations in cardiothoracic department.A pre-test–post-test quasiexperimental study was conducted in a cardiothoracic ward at a tertiary teaching hospital in Suzhou, China. Patients admitted to the ward were collected as baseline group (2011.7–2012.12) and intervention group (2013.7–2014.12), respectively. The criteria of prophylaxis antibiotic utilization were established on the basis of the published guidelines and official documents. During the intervention phase, a dedicated pharmacist was assigned and multifaceted interventions were implemented in the ward. Then we compared the differences in antibiotic utilization, bacterial resistance, clinical and economic outcomes between the 2 groups. Furthermore, patients were collected after the intervention (2015.1–2015.6) to evaluate the sustained effects of pharmacist interventions.412 and 551 patients were included in the baseline and intervention groups, while 156 patients in postintervention group, respectively. Compared with baseline group, a significant increase was found in the proportion of antibiotic prophylaxis, the proportion of rational antibiotic selection, the proportion of suitable prophylactic antibiotic duration, and the proportion of suitable timing of administration of the first preoperative dose (P < 0.001). Meanwhile, a significant reduction was seen in the rate of unnecessary replacement of antibiotics and the rate of unnecessary combinations (P < 0.001). Besides, pharmacist intervention resulted in favorable outcomes with significantly decreased rates of surgical site infections, prophylactic antibiotic cost, and significantly shortened length of stay (P < 0.05). Furthermore, there were also significant decreases of the rates of antibiotic resistant enterobacter cloacae, klebsiella pneumonia, and staphylococcus aureus (P < 0.05). Moreover, the effects were sustained after discontinuation of the active interventions, as shown in prophylactic antibiotic utilization data.Pharmacist interventions in cardiothoracic surgery result in a high adherence to evidence-based treatment guidelines and a profound culture change in drug prescribing with favorable outcomes. The effects of pharmacist intervention are sustained and the role of pharmacists is emphasized for rational medication and optimal outcomes in clinical treatment.     

Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units

BACKGROUND: Previous studies found that medication errors result from lack of sufficient information during the prescribing step. Therefore, it is proposed that having a pharmacist available when patients are evaluated during the rounding process may reduce the likelihood of preventable adverse drug events (ADEs). The objectives of this study were to evaluate the impact of having a pharmacist participate with a physician rounding team on preventable ADEs in general medicine units and to document pharmacist interventions made during the rounding process. METHODS: A single-blind, standard care-controlled study design was used to compare patients receiving care from a rounding team including a pharmacist with patients receiving standard care (no pharmacist on rounding team). Patients admitted to and discharged from the same general medicine unit were included in the study. The main outcome measure of this study was preventable ADEs. Patient records were randomly selected and evaluated by a blinded process involving independent senior pharmacist specialists and a senior staff physician. Interventions made by the pharmacists in the treatment group were documented. RESULTS: The rate of preventable ADEs was reduced by 78%, from 26.5 per 1000 hospital days to 5.7 per 1000 hospital days. There were 150 documented interventions recommended during the rounding process, 147 of which were accepted by the team. The most common interventions were (1) dosing-related changes and (2) recommendations to add a drug to therapy. CONCLUSION: Pharmacist participation with the medical rounding team on a general medicine unit contributes to a significant reduction in preventable ADEs.     

The impact of pharmacist care on diabetes outcomes in primary care settings: An umbrella review of published systematic reviews

ObjectiveTo systematically review published systematic reviews (SRs) examining the impact of pharmacist interventions in multidisciplinary diabetes care teams on diabetes-related clinical, humanistic, and economic outcomes in primary care settings.MethodsPubMed, EMBASE, Scopus, Database of Abstracts of Reviews of Effects, Cochrane Library, Joanna Briggs Institute (JBI) Database, Google Scholar, and PROSPERO were searched from inception to 2018. Studies published in English evaluating the effect of pharmacist interventions on diabetes outcomes were included. Two independent reviewers were involved in screening of titles and abstracts, selection of studies, and methodological quality assessment.ResultsSeven SRs were included in the study. Three of them included only randomized controlled trials, while the rest involved other study designs. Educational interventions by clinical pharmacists within the healthcare team were the most common types of interventions reported across all SRs. Pharmacist’s interventions compared to usual care resulted in favorable significant improvements in hemoglobin A_1c (HbA_1c), fasting blood glucose, blood pressure, body mass index, total cholesterol, low density lipoprotein, high density lipoprotein and triglycerides in more than 50% of the SRs. Improvement in HbA_1c was the mostly reported clinical outcome of pharmacist intervention in the literature (reported in six SRs). Pharmacist’s interventions led to significant cost-saving ($8–$85,000 per person per year), cost-utility, and cost-benefit (benefit-to-cost ratio range from 1:1 to 8.5:1) versus usual care. Pharmacist’s interventions improved patients’ quality of life (QoL) in three SRs; however, no conclusion can be drawn due to the use of diverse QoL assessment tools.ConclusionsMost SRs support the benefit of pharmacist care on diabetes-related clinical, humanistic, and economic outcomes in primary care settings. Improvements in diabetes outcomes can significantly reduce the burden of diabetes on healthcare system. Hence, the incorporation of pharmacists into multidisciplinary diabetes care teams is beneficial and should be strongly considered by clinicians and health policymakers.     

Effectiveness of the Pharmacist-Involved Multidisciplinary Management of Heart Failure to Improve Hospitalizations and Mortality Rates in 4630 Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BackgroundThere is evidence that heart failure (HF) patients who receive pharmacist care have better clinical outcomes.Methods and ResultsEnglish-language peer-reviewed randomized controlled trials comparing the pharmacist-involved multidisciplinary intervention with usual care were included. We searched PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, and the Cochrane Library from inception through March 2017. Cochrane method for risk of bias was used to assess within and between studies. 18 RCTs (n = 4630) were included for systematic review, and 16 (n = 4447) for meta-analysis. Meta-analysis showed a significant reduction in HF hospitalizations {odds ratio (OR) 0.72 [95% confidence interval (CI) 0.55-0.93], P = .01, I2 = 39%} but no effect on HF mortality. Similarly, a significant reduction in all-cause hospitalizations [OR 0.76, 95% CI (0.60-0.96), P = .02, I2 = 52%] but no effect on all-cause mortality was revealed. The overall trend was an improvement in medication adherence. There were significant improvements in HF knowledge (P<.05), but no significant improvements were found on health care costs and self-care.ConclusionsThe pharmacist is a vital member of a multidisciplinary team in HF management to improve clinical outcomes. There was a great deal of variability about which specific intervention is most effective in improving clinical outcomes.     

Medication errors in hospitalized cardiovascular patients

BACKGROUND: The Institute of Medicine's report To Err Is Human: Building a Safer Health System recommends pharmacist participation in patient rounds as an immediate approach to reducing medical errors. In the same report and in prior publications, cardiovascular drugs have been commonly associated with severe adverse drug events. METHODS: We systematically reviewed the experience of a clinical pharmacist on the cardiology wards between September 1, 1995, and February 18, 2000. We classified medication errors according to the type of error, medications involved, personnel involved, stages of drug administration involved, and time of year most frequently associated with errors. RESULTS: Among 14983 pharmacist interventions, 4768 were related to medication errors, or 24 medication errors per 100 admissions. The most common errors involved the wrong drug (36.0%) or wrong dose (35.3%), and cardiovascular medications were involved in 41.2% of the errors. Prescribers were associated with most of the errors, and the transition from outpatient to inpatient was the most common point in the system for the occurrence of these medication errors. Higher numbers of errors were also identified during the transition period of house staff, and the total number of errors increased during the study period. CONCLUSIONS: Through the clinical pharmacist's identification and correction of medication errors, 2 areas of improvement that may reduce medication errors were identified. The first is ensuring accurate knowledge of a patient's outpatient medication regimen. The second involves improving the education and support of new interns during their initial months of training. This work exemplifies the approach recommended by the Institute of Medicine to reduce medical errors through systematic analyses rather than ascribing fault to individuals.     

Impact of the Chronic Care Model on medication adherence when patients perceive cost as a barrier

AimsCost burdens represent a significant barrier to medication adherence among chronically ill patients, yet financial pressures may be mitigated by clinical or organizational factors, such as treatment aligned with the Chronic Care Model (CCM). This study examines how perceptions of chronic illness care attenuate the relationship between adherence and cost burden.MethodsSurveys were administered to patients at 40 small community-based primary care practices. Medication adherence was assessed using the 4-item Morisky scale, while five cost-related items documented recent pharmacy restrictions. CCM experiences were assessed via the 20-item Patient Assessment of Chronic Illness Care (PACIC). Nested random effects models determined if chronic care perceptions modified the association between medication adherence and cost-related burden.ResultsOf 1823 respondents reporting diabetes and other chronic diseases, one-quarter endorsed intrapersonal adherence barriers, while 23% restricted medication due of cost. Controlling for age and health status, the relationship between medication cost and CCM with adherence was significant; including PACIC scores attenuated cost-related problems patients with adequate or problematic adherence behavior.ConclusionsPatients experiencing treatment more consistent with the CCM reported better adherence and lower cost-related burden. Fostering highly activated patients and shared clinical decision making may help alleviate medication cost pressures and improve adherence.     

An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing

BACKGROUND: efficient strategies are needed to provide specialist advice in nursing homes to ensure quality medical care. We describe a case conference intervention involving a multidisciplinary team of health professionals. OBJECTIVES: to evaluate the impact of multidisciplinary case conferences on the appropriateness of medications and on patient behaviours in high-level residential aged care facilities. DESIGN: cluster-randomised controlled trial. SETTING: ten high-level aged care facilities. PARTICIPANTS: 154 residents with medication problems and/or challenging behaviours were selected for case conference by residential care staff. INTERVENTION: two multidisciplinary case conferences involving the resident's general practitioner, a geriatrician, a pharmacist and residential care staff were held at the nursing home for each resident. MEASUREMENTS: outcomes were assessed at baseline and 3 months. The primary outcome was the Medication Appropriateness Index (MAI). The behaviour of each resident was assessed via the Nursing Home Behaviour Problem Scale. RESULTS: 45 residents died before follow-up. Medication appropriateness improved in the intervention group [MAI mean change 4.1, 95% confidence interval (CI) 2.1-6.1] compared with the control group (MAI mean change 0.4, 95% CI -0.4-1.2; P < 0.001). There was a significant reduction in the MAI for benzodiazepines (mean change control -0.38, 95% CI -1.02-0.27 versus intervention 0.73, 95% CI 0.16-1.30; P = 0.017). Resident behaviours were unchanged after the intervention and the improved medication appropriateness did not extend to other residents in the facility. CONCLUSION: multidisciplinary case conferences in nursing homes can improve care. Outreach specialist services can be delivered without direct patient contact and achieve improvements in prescribing.     

Interprofessional Collaboration to Improve Discharge from Skilled Nursing Facility to Home: Preliminary Data on Postdischarge Hospitalizations and Emergency Department Visits

An interprofessional collaborative practice model was established at Hennepin County Medical Center to improve discharge management from the transitional care unit of the skilled nursing facility (SNF) to home. The practice model involves a geriatrician, nurse practitioner, and pharmacist who care for individuals at a community‐based SNF. Before SNF discharge, the pharmacist conducts a chart and in‐person medication review and collaborates with the nurse practitioner to determine the discharge medication regimen. The pharmacist's review focuses on assessing the indication, safety, effectiveness, and convenience of medications. The pharmacist provides follow‐up in‐home or over the telephone 1 week after SNF discharge, focusing on reviewing medications and assessing adherence. Hospitalizations and emergency department (ED) visits 30 days after SNF discharge of individuals who received care from this model was compared with those of individuals who received usual care from a nurse practitioner and geriatrician. From October 2012 through December 2013, the intervention was delivered to 87 individuals, with 189 individuals serving as the control group. After adjusting for age, sex, race, and payor, those receiving the intervention had a lower risk of ED visits (odds ratio (OR) = 0.46, 95% confidence interval (CI) = 0.22–0.97), although there was no significant difference in hospitalizations (OR = 0.47, 95% CI = 0.21–1.08). The study suggests that an interprofessional approach involving a pharmacist may be beneficial in reducing ED visits 30 days after SNF discharge.     

Fetal Sex and Maternal Asthma Control in Pregnancy

Many elderly patients in nursing homes in the United States use metered-dose inhaler (MDI) medications for a variety of lung diseases. We wondered how much the nursing support staff knew about correct MDI inhaler technique. Thirty-eight nursing home support staff were asked to demonstrate correct use of a placebo MDI inhaler on themselves. The staff completed an average of 6.9 steps out of 8 correctly. The most common error demonstrated was the staff did not hold their breath for 10 seconds at full inspiration after inhaling the medication. The results suggest that the support staff have incorrect MDI inhaler technique.