Category: Federal Forum Posters
Purpose: It is projected there will be 8 million Americans with heart failure (HF) in 2030. In the United States, HF costs exceeded $30 billion in 2012 with direct medical costs totaling 68% of expenses. HF is an ambulatory care sensitive condition (ACSC) and medication optimization is crucial in improving morbidity and mortality, therefore reducing hospitalizations in high risk HF patients. Including pharmacists in patient care teams improves patient outcomes. The primary objective of this project was to develop and implement a pharmacist-led clinic focused on medication titration and optimization in high risk heart failure with reduced ejection fraction (HFrEF) patients.
Methods: This quality improvement project was approved by the Pharmacy and Therapeutics Committee and did not require IRB approval. A pilot VA ACSC database identified Veterans with a HF diagnosis who were at high risk for hospitalization. Patients were included for enrollment into the pharmacotherapy heart failure clinic (PHFC) if they were identified as having ≥ 85% chance of hospitalization within the next year and if they had a current/previous ejection fraction (EF) ≤ 40%. Patients were excluded if they were actively managed by cardiology, were enrolled in home-based primary care (HBPC), were considered inpatient status or hospice care, no longer resided in the catchment area, or if their provider refused clinic referral. Preliminary chart reviews were conducted to assess inclusion/exclusion criteria. Patients who met criteria had consults entered for provider signature to allow for PHFC enrollment. The following data was collected during initial chart reviews: demographics, comorbidities, EF history, laboratory data, vital signs, and HF medications. At the completion of the intervention window, a retrospective chart review was conducted to collect vitals, laboratory data, medication changes, and other pharmacist interventions. The primary outcome was the percentage of patients enrolled in PHFC who achieved guideline-directed medical therapy (GDMT). The secondary outcomes were the percentage of patients on target or maximally tolerated doses of angiotensin converting enzyme inhibitors (ACEi)/angiotensin II receptor blockers (ARBs) and beta blockers (BB).
Results: Fourteen patients were enrolled in the PHFC, with 6 of these patients carrying a diagnosis of HFrEF that allowed for active management of HF medication regimens. At the completion of the intervention window, 5 patients (83%) were on guideline-recommended ACEi/ARB and BB therapy. Five patients (83%) were on their maximally tolerated BB dose and none of the patients enrolled in the PHFC were able to reach target dose as recommended by the current guidelines. Four patients (67%) were on their maximally tolerated ACEi/ARB dose, with 2 patients (30%) achieving target dose as recommended by the current guidelines. Pharmacist interventions made during the intervention window included lab monitoring (renal function, overdue digoxin monitoring), triage to urgent care, re-titration of BB after unintentional discontinuation by patient, and care coordination with cardiology. Of patients that were excluded, no documentation of EF ≤ 40% accounted for 82 patients while 35 patients were excluded for reasons outlined above.
Conclusion: It appears that the highest risk HFrEF patients identified at our facility were receiving GDMT even prior to the implementation of the PHFC. Despite this, the clinical pharmacy specialist was able to make significant interventions to improve patient care. The pilot VA ACSC database did not appropriately identify the highest risk HF patients at this facility. A small percentage of patients identified had the targeted HFrEF diagnosis which resulted in significantly less patients than anticipated. Despite these limitations, the project demonstrates the potential value of the pharmacist and the need for expanded projects to better target high risk HFrEF patients.