Optimizing Heart Failure Management: A Review of the Clinical Pharmacist Integration to the Multidisciplinary Health Care Team

- ¹Pharmacy Department, Hospital Clínica Bíblica, San José, Costa Rica.
- ²Heart Failure Program, Hospital Clínica Bíblica, San José, Costa Rica.
- ³Faculty of Pharmacy, Universidad de Ciencias Médicas, San José, Costa Rica.
- ⁴Faculty of Pharmacy, University of Costa Rica, San José, Costa Rica.
Correspondence to Esteban Zavaleta-Monestel, PharmD. Pharmacy Department and Heart Failure Program, Hospital Clínica Bíblica, Laberinto, San José 10104, Costa Rica. Email: ezavaleta@clinicabiblica.com

Received April 18, 2023; Revised September 01, 2023; Accepted October 23, 2023.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Heart failure (HF) stands as a prevalent chronic ailment, imposing a substantial burden on global healthcare systems due to recurrent hospitalizations, intricate management, persistent symptoms, and polypharmacy challenges. The augmentation of patient safety and treatment efficacy across various care stages, facilitated by a multidisciplinary HF team inclusive of a clinical pharmacist, emerges as paramount. Evidence underscores that the collaborative engagement of a physician and a clinical pharmacist engenders proficient and secure management, forestalling avoidable adversities stemming from drug reactions and prescription inaccuracies. This synergistic approach tailors treatments optimally to individual patients. Post-discharge, the vulnerability of HF patients to re-hospitalization looms large, historically holding sway as the foremost cause of 30-day readmissions. Diverse strategies have been instituted to fortify patient well-being, leading to the formulation of specialized transitional care programs that shepherd patients effectively from hospital to outpatient settings. These initiatives have demonstrably curtailed readmission rates. This review outlines a spectrum of roles assumed by clinical pharmacists within the healthcare cohort, spanning inpatient care, transitional phases, and outpatient services. Moreover, it traverses a compendium of studies spotlighting the affirmative impact instigated by integrating clinical pharmacists into these fields.

Keywords

Clinical pharmacist; Heart failure; Pharmaceutical services; Medication adherence

INTRODUCTION

Heart failure (HF) is a significant and escalating chronic ailment with a global incidence, impacting more than 60 million individuals worldwide. This condition is marked by an insufficient capacity to pump blood effectively, resulting in compromised perfusion. It is known for recurrent episodes of decompensation, leading to frequent hospitalizations with readmission rates ranging from 30% to 40%.1, 2, 3, 4, 5) In the United States of America and Europe, the prevalence of HF ranges from 1% to 2%, while in Asian countries like South Korea, it reached a maximum value of 2.24% in 2018.6, 7, 8) The substantial prevalence of HF imposes a significant economic burden on healthcare systems worldwide. In 2012, the estimated annual cost of HF management was 30.7 billion USD in the United States, 33.14 billion USD in the European Union, and 1.1 billion USD in South Korea.9, 10, 11)

Inadequate communication between healthcare providers in the inpatient and outpatient settings significantly contributes to an elevated risk of readmission and mortality. Collaborative care among healthcare professionals, including cardiologists, nurses trained in cardiology, and pharmacists, is crucial for improving patient outcomes.12)

Transitions of care (TOC) often involve medication errors that can result in medication-related adverse reactions. A significant proportion of patients, up to 70%, experience unintended changes in their medication regimen during these transitions. Disturbingly, around 30% of these medication changes lead to worsened outcomes, and approximately 5–8% of patients require readmission to the hospital due to medication-related issues.12, 13)

The proactive engagement of pharmacists in prescription reviews, coupled with their seamless integration into multidisciplinary teams, holds immense significance. Their pivotal role in overseeing and detecting prescription errors to avert medication-related issues cannot be overstated. This synergistic methodology guarantees the execution of refined, secure, and effective therapeutic regimens, culminating in enhanced patient outcomes.14) A recent study has highlighted the significant impact of a multidisciplinary TOC team, including clinical pharmacists, residents, students, and HF-trained nurses, in mitigating 30-day readmission rates for HF patients with cardiovascular symptoms. By integrating medication reconciliation at every juncture of the TOC process, a significant decrease of 2% in readmission rates was accomplished. These results underscore the efficacy of engaging a multidisciplinary team in mitigating hospital readmissions for individuals with HF, consequently enhancing patient outcomes and potentially diminishing healthcare expenditures.15)

This review aims to elucidate the various activities that clinical pharmacists can undertake as part of the multidisciplinary management of HF across different stages of care and to evaluate the supporting literature for their effects.

CLINICAL PHARMACIST’S ACTIVITIES DURING OUTPATIENT HF MANAGEMENT

When managing HF, adopting a guideline-directed medical therapy (GDMT) approach has shown superior efficacy compared to limited treatment plans. GDMT has demonstrated a reduction in both mortality and morbidity within 30 days of commencing treatment.16) Despite concerns surrounding the use of multiple medications (polypharmacy), GDMT has proven to be a beneficial strategy in managing HF, improving quality of life, increasing survival rates, and reducing mortality. However, the complexity of medication regimens can sometimes result in undesirable reactions and intolerance. It is crucial to regularly evaluate and adjust medications to ensure their safety and effectiveness. Table 1 provides a summary of common adverse reactions that can occur with these medications.17, 18, 19, 20, 21, 22, 23, 24, 25, 26) Given the vast array of available drugs and the possibility of adverse reactions, it is essential to closely monitor the patient’s response to therapy at every stage of care to achieve positive outcomes.27)

Table 1
Common drug adverse of medication used for the management of chronic heart failure and acute decompensated heart failure17, 18, 19, 20, 21, 22, 23, 24, 25, 26)

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Medication compliance

One of the primary challenges faced by patients with HF lies in achieving medication compliance by providing appropriate treatment adherence guidance.28) Educating patients, their families, and caregivers is one of the main points of interest in pharmacy care. Medication adherence is one of the most studied topics when referring to pharmaceutical care, which is achieved through education to patients and their close circle.29) There have been numerous investigations into the impact of engaging a pharmacist in post-treatment consultations on patient adherence to prescribed medication. By complying with the recommended treatment plan, healthcare providers can more effectively monitor patient progress and evaluate their overall health outcomes.30, 31)

Certain authors expand the notion of treatment adherence when it comes to patients with HF, given the significance of dietary considerations and daily actions. Consequently, an inclusive approach that encompasses monitoring medication compliance, adherence to dietary recommendations, and fostering patient awareness of their condition has emerged as a relatively recent objective in the ambulatory management of HF. This holistic approach has been integrated into pharmacy consultations to address treatment adherence. The active practice of this new concept of treatment adherence is directly related to a better prognosis, being that non-adherent patients have an increased risk of 22% being hospitalized, in comparison to adherent patients.28) For this reason, various strategies have been developed to measure HF medication adherence, including checking the prescription refill history of HF medication, insurance history, pill counts, serum drug levels, questionnaires, and patient self-reports.32) Table 2, 32, 33) illustrates some common strategies used to improve medication adherence. When consulting a polymedicated patient, it’s worth noting that some tendencies indicate if the patient may or may not be adherent to their treatment; these tendencies are shown in Table 3.32)

Table 2
Strategies for improving patient’s adherence to treatment32, 33)

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Table 3
Predictors associated with therapy adherence on heart failure patients

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Optimization of GDMT

Pharmacist-directed HF programs have demonstrated success in enhancing GDMT prescription rates. GDMT has proven to be significantly more effective than restricted treatment plans in promoting positive outcomes for HF patients. The presence of a clinical pharmacist within the HF program enables personalized dosing for each patient, facilitating timely adjustments and attainment of target doses. This not only benefits the patient’s recovery but also optimizes the HF clinics’ operations. The importance of timely and optimized dosing cannot be overstated, as studies have found that every month of delay in reaching the target dose is associated with a 1% decrease in survival rates.16, 34)

Due to the intricate dosing requirements of HF medications, patients face a clear disadvantage. In a multinational study involving 29,546 patients, the attainment of goal doses following HF guidelines was assessed. The findings revealed that only 30% of the population was able to achieve these goal doses. In a different cohort study in Germany with a sample of 26,191 patients similar results were found, where only 21% of patients reached goal doses. The causes attributed to these findings were a lack of medication compliance and the lack of knowledge from the clinicians about the clinical guidelines.35) This tendency can represent a clear limitation if new promising drugs such as vericiguat, which proved to decrease mortality and hospitalization rates, are initiated, as the four-week titration period involves every follow-up to measure tolerability and clinical response.19, 36, 37) The follow-ups from the clinical pharmacist during the different titration periods can play a crucial role in achieving goal doses early or treating the patients according to their tolerability.

According to a recent study conducted by University of California, Los Angeles, the inclusion of pharmacists in a HF clinic had a significant impact on patient outcomes. The study involved 153 patients and revealed that having a pharmacist present resulted in patients reaching their target doses more efficiently and promptly, resulting in a 94% fulfillment rate for GDMT. Furthermore, follow-up visits were reduced from an average of 23 days to just 13 days. Most notably, the study demonstrated a notable decrease in all-cause mortality rates.16) Another study involving 1,568 patients also yielded positive results after incorporating clinical pharmacists into a HF clinic. The intervention group experienced a decrease in non-fatal cardiovascular events, which led to fewer hospital admissions and emergency room visits compared to the control group. Although not statistically significant, the study also observed a decrease in overall mortality rates in the intervention group.38)

These positive outcomes are significant because, despite the well-known positive effects of angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitor, beta-blockers, and mineralocorticoid receptor antagonists, it is well-documented that these therapies are not prescribed with optimal doses.29) For this reason, prescribing errors and dosing titration timing are monitored in clinical pharmacy care daily, evaluating patient needs, evolution with a determined drug regimen, and accomplished treatment compliance.14, 29) Pharmacists are well-trained to play a key role in this regard, given their expertise in promoting safe medication use, reducing prescribing errors, and providing dosing guidance for high-complexity patients or special populations such as those with renal or hepatic impairment patients, but these are just mere examples of how pharmacists can significantly contribute to the multidisciplinary management of HF.27, 39)

New strategies for outpatient pharmacy follow-up

Due to the COVID-19 pandemic, there has been an increased prevalence of telehealth or telephonic consultations with healthcare providers. In the tele-management of outpatients with HF, clinical pharmacists have been conducting follow-ups with high-risk, non-adherent patients. This intervention has yielded positive outcomes, leading to a significant 41% reduction in mortality over two years. It is important to note that this was a relatively small-scale study involving only 16 patients. Nonetheless, the study observed that efficient timing in therapy optimization remained evident despite the telehealth management, and there was also a notable reduction in the need for in-person hospital services.40)

One of the key advantages of pharmacy consults in this context is the ability to thoroughly assess the patient’s condition, monitor the progression of HF, and identify its correlations with comorbidities and treatment. This comprehensive evaluation allows for the timely prevention of decompensation or early initiation of medical referrals.41)

CLINICAL PHARMACIST’S ACTIVITIES DURING INPATIENT HF MANAGEMENT

In the intensive care unit (ICU), pharmacists play a critical role in supporting patients who are in critical condition and face unique pharmacokinetic challenges. By working as part of a multidisciplinary critical care team, pharmacists can gain a comprehensive understanding of individual cases, which leads to well-informed decision-making. While there have been limited studies on the role of pharmacists in managing hospitalized patients with HF, many of the activities that are relevant to ICU patients can be applied to less complex cases for optimal quality of care. This section aims to explore the various activities that pharmacists undertake when caring for hospitalized patients.42)

Preventable adverse drug reactions

Preventable adverse drug reactions (ADEs) are a focus of clinical pharmacists’ activities, both for hospitalized and ambulatory patients. ADEs can be categorized into intrinsic and extrinsic harm. Intrinsic harm arises from the medication’s pharmacologic properties, leading to proper adverse drug reactions. On the other hand, extrinsic harm results from medication errors, such as administering medication intravenously instead of intramuscularly. While many drug-related adverse reactions are well-documented, some of them are preventable. Clinical physicians conduct follow-ups to assess the safety of therapies for patients and identify strategies to prevent or control high-risk ADEs before they manifest.43)

Monitoring for preventable ADEs, their occurrence, and potential drug interactions are of paramount importance for patients with polypharmacy, a concern that is equally pertinent for HF patients, as previously discussed. In the management of complex patients characterized by a myriad of comorbidities and a multitude of prescribed medications, it becomes imperative to scrutinize the safety of the prescribed regimen. This entails a comprehensive analysis of parameters about drug efficacy and safety. Notably, it is not uncommon for HF patients to either already have or develop renal impairment, making it essential to monitor renal function closely and adjust medication doses accordingly. As an illustrative example, renal function can significantly impact the pharmacokinetics of certain medications, necessitating precise dose titrations. Additionally, populations such as older adults or individuals with significant weight fluctuations, who may present challenges in terms of anticoagulant therapy management, require careful attention and expertise to ensure safe and effective treatment. In these intricate scenarios, the active involvement of a clinical pharmacist can be invaluable, contributing substantively to the multidisciplinary healthcare team’s efforts to optimize patient care and therapeutic outcomes.42)

In the treatment of HF patients with multiple comorbidities, the multitude of medications involved can be overwhelming. Clinical pharmacists play a vital role in identifying potential drug-drug and food-drug interactions using various tools. These interactions are assessed based on probability, risk-benefit, and severity, allowing the clinical pharmacist to provide valuable guidance and support to the prescribing doctor in determining the most appropriate pathway when facing medication-related issues.44)

Medication management

Patients with complex conditions, such as those with HF, require close monitoring of clinical parameters and overall clinical progress to determine the efficacy of treatment outcomes. Clinical pharmacists play a crucial role in assessing various aspects of the prescribed medication regimen, including its safety, appropriateness, indication, and effectiveness. They have the expertise to initiate, discontinue, modify, or adjust medication doses to achieve the most favorable patient outcomes. This comprehensive evaluation and the activities collectively constitute comprehensive medication management (CMM), which aims to personalize therapy based on the unique needs of each patient. CMM encompasses addressing current symptoms, managing existing conditions, and preventing future complications and can be applied in both inpatient and outpatient settings.42, 45)

The process of CMM comprises four essential steps. Firstly, the patient’s needs are assessed, allowing for the identification of any medication-related issues. In the second step, the prescribed medication regimen is evaluated in terms of necessity, safety, and effectiveness. Based on this evaluation, a plan is developed in the third step to optimize medication therapy. Finally, the plan is implemented, and the patient’s progress is continuously monitored and evaluated in the fourth step to ensure that desired outcomes are achieved.42, 45)

The studies on the effect of these activities show a decrease in the incidence of preventable ADEs caused by prescription errors, which translated to a more likely discharge, avoiding extension of hospital stays and the consequent economic savings. In complicated patients such as ICU patients, a substantial decrease in mortality due to bleeding was also found, this sort of study then led to the question of how high the rate of prescribing errors is associated with mortality. Because of this, some institutions recruited ICU-trained clinical pharmacists to reduce the incidence of ADEs, prescribing errors, and implementation of a CMM, but this sort of complication is not exclusive to critically ill patients and can be extended to less complicated patients to ensure the best quality of care, but the study of the effect of clinical pharmacists on different wards is yet to be conducted.46)

CLINICAL PHARMACIST’S ACTIVITIES AS PART OF THE TOC TEAM

To ensure optimal treatment for HF patients, it is crucial to have a specialized team dedicated to TOC. This team should handle all aspects of the patient’s treatment, from admission and hospitalization prescriptions to discharge medication. Due to the complex medical histories and comorbidities of HF patients, they are at a higher risk of adverse medication reactions and prescription errors. Therefore, a multidisciplinary TOC team is necessary to prevent undertreatment, overtreatment, duplication of therapy, omissions, and drug interactions. The TOC team works to ensure that the patient receives safe and efficient treatment tailored to their specific needs, and they also monitor the patient’s medication history to prevent errors. To achieve this, the team coordinates patient care during transitions between healthcare settings, using interventions that optimize patient outcomes.47)

Following discharge from the hospital, adherence to the prescribed ambulatory care medication regimen is of paramount importance for the effective management of HF. This debilitating condition has been identified as the primary cause of 30-day readmissions for several years, underscoring the critical role of the TOC team in ensuring patient safety. Within the healthcare industry, 30-day readmission is widely regarded as an indication of suboptimal health management during the transition between stages of care. Contributing factors may include inconsistencies in medication administration, limited access to healthcare, inadequate knowledge of self-care practices, insufficient follow-up care, and financial constraints.48) As a strategy to decrease the 30-day readmission rates transitional care pharmacists have implemented a system of medication reconciliation before discharge, patient education, discharge counseling, phone follow-ups, and multidisciplinary home visits, which have effectively decreased readmission rates of HF patients, eventually as part of the HF clinics that have implemented a HF-TOC patients then will be followed up in regular outpatient appointments.49, 50, 51, 52, 53)

Numerous meta-analyses have explored the impact of TOC interventions. A noteworthy analysis delved into 53 clinical trials, encompassing more than 12,000 patients from 2000 to 2015. The findings indicate that individuals who received guidance from the TOC team during the post-discharge phase had a substantial drop in readmission rates, ranging from 20–35%.51) A different meta-analysis intended to identify which actions contribute to an effective decrease in readmission rates, these different activities are presented in Table 4.52)

Table 4
Identified activities of the clinical pharmacist that cause a decrease in 30-day readmission through a HF-TCP52)

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The clinical pharmacist’s role during discharge planning includes an integral overview of the condition of the patient and involves most of the different activities already mentioned in Table 4. Additionally, before discharge, a revision of contraindicated drugs in HF patients is conducted; these contraindicated drugs are illustrated in Table 5.33, 54) These actions are particularly important because the collaboration between physicians and pharmacists when establishing a management plan has proven positive on patient outcomes, achieving better prognosis and early results.52, 55) A general summary of the role of the clinical pharmacist in the multidisciplinary approach to HF treatment is presented in Figure 1.

Table 5
Drugs with the capability of causing or exacerbating heart failure

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Figure 1
Role of the clinical pharmacist in the multidisciplinary approach to heart failure treatment.

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CONCLUSIONS

Based on the reviewed literature, it is notable that pharmacists can play a crucial role in the multidisciplinary healthcare team, contributing to the optimal management of patients with HF in the different stages of care. As medication management is a critical aspect of HF treatment, the involvement of an expert in pharmacology, pharmacokinetics, therapeutics, and medication compliance can greatly favor treatment optimization, making treatment-based monitorization regular and achieving medication compliance possible, these different activities can improve patient’s condition and help to accomplish positive outcomes. In conclusion, the pharmacists' inclusion in the multidisciplinary team can contribute to accomplishing an optimized and individualized therapy, active use of GDMT, accurate timing for medication titration, and an exhaustive review of how safe the prescribed regimen is, including not only HF treatment. The sum of these activities can influence importantly in achieving positive outcomes, maintaining a stable disease, preserving the quality of life, and consequently, decreasing mortality and hospitalization rates.

Notes

Conflict of Interest:The authors have no financial conflicts of interest.

Author Contributions:

Conceptualization: Zavaleta-Monestel E, Arguedas-Chacón S, Speranza-Sanchez MO.
Formal analysis: Zavaleta-Monestel E, Arguedas-Chacón S, Quirós-Romero A, Serrano-Arias B.
Investigation: Zavaleta-Monestel E, Arguedas-Chacón S, Díaz-Madriz JP, Speranza-Sanchez MO.
Methodology: Zavaleta-Monestel E, Arguedas-Chacón S, Quirós-Romero A, Chaverri-Fernández JM, Serrano-Arias B, Díaz-Madriz JP, Speranza-Sanchez MO.
Resources: García-Montero J.
Supervision: Zavaleta-Monestel E, Chaverri-Fernández JM.
Validation: Zavaleta-Monestel E, Chaverri-Fernández JM, Serrano-Arias B, García-Montero J, Speranza-Sanchez MO.
Writing - original draft: Zavaleta-Monestel E, Arguedas-Chacón S, Quirós-Romero A, Chaverri-Fernández JM, Serrano-Arias B, Díaz-Madriz JP, García-Montero J, Speranza-Sanchez MO.
Writing - review & editing: Zavaleta-Monestel E, Arguedas-Chacón S, Quirós-Romero A, Chaverri-Fernández JM, Serrano-Arias B, Díaz-Madriz JP, García-Montero J, Speranza-Sanchez MO.

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