FAQ
Pharmacist’s role in the management of heart failure patients
Heart failure affects approximately 5 million Americans and the prevalence of this condition is rising every year. It is estimated that 550,000 new heart failure diagnoses occur annually. Heart failure is associated with significant morbidity and mortality. Approximately 50% of patients are rehospitalized and 40% die within 1 year of an initial hospitalization for the condition. According to current practice guidelines, heart failure is managed with a combination of lifestyle modifications and drug therapy that includes angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, digoxin, aldosterone antagonists, and diuretics. Pharmacists can play a key role in reducing morbidity and mortality by ensuring that appropriate therapies are prescribed and that patients are adhering to treatment regimens.
Sheri Koshman and colleagues published a meta-analysis of randomized controlled trials evaluating the impact of pharmacist care on the management of patients with heart failure. The investigators searched various electronic databases from their initiation through August 2007 including PubMed/MEDLINE, EMBASE, International Pharmaceutical Abstracts, Web of Science, Scopus, Dissertation Abstracts, CINAHL, PASCAL, and Cochrane Central Registry of Controlled Trials to identify randomized controlled trials that evaluated the impact of pharmacist activities on patients with heart failure compared with no pharmacist care. The primary outcomes of trials included in the meta-analysis were all-cause hospitalizations, heart failure hospitalizations, and all-cause mortality. Secondary outcomes such as health-related quality-of-life measures and medication adherence were also evaluated. Pharmacist interventions were classified as either "pharmacist-directed care" defined as pharmacist-initiated and managed interventions or as "pharmacist collaborative care" in which the pharmacist functioned as part of a multidisciplinary team.
Of the 3115 citations identified and screened, 12 trials (n = 2060) were included in the meta-analysis. Seven trials were classified as pharmacist-directed care and 5 trials were classified as pharmacist collaborative care. The pharmacist-specific interventions in these studies generally involved education about heart failure and medications, self-monitoring tips, medication management, and adherence. Overall, a pooled analysis of the 12 trials showed no significant reduction in all-cause mortality (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.61 to 1.15). However, a pooled analysis of 11 trials (n = 2026) revealed that all-cause hospitalization rates (OR 0.71, 95% CI 0.54 to 0.94) were significantly reduced when a pharmacist was involved in the patient’s care. Additionally, a pooled analysis of 11 trials (n = 1977) showed that heart failure hospitalization rates (OR 0.69, 95% CI 0.51 to 0.94) were also significantly reduced when a pharmacist was involved in the care of patients. Pooled analyses of secondary outcomes such as health-related quality-of-life and medication adherence were not performed because only a small number of studies evaluated health-related quality-of-life, and methods for measuring adherence varied substantially among the trials.
When comparing pharmacist-directed care and pharmacist collaborative care, no significant differences between the 2 interventions were noted in their effects on mortality or all-cause hospitalizations (p=0.4 for both). However, pharmacist collaborative care was associated with a greater risk reduction in heart failure hospitalization rates compared with pharmacist-directed care (p=0.02). The investigators commented that this finding was not surprising because medication management and patient education by a pharmacist would complement care give by other members of the health care team.
The current meta-analysis shows that some type of pharmacist care in the management of patients with heart failure can have a positive impact by reducing hospitalization rates. Although this analysis failed to show a benefit of pharmacist interventions on all-cause mortality, the investigators attributed this finding to a small overall sample size and a short duration of follow-up in the majority of studies (studies ranged from 2 days to 12 months in duration).
References
Parker RB, Patterson JH, Johnson JA. Heart failure. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiological Approach. 6th ed. New York, NY: McGraw-Hill; 2005:219–260.
Koshman SL, Charrois TL, Simpson SH, McAlister FA, Tsuyuki RT. Pharmacist care of patients with heart failure. Arch Intern Med. 2008;168(7):687-694.
Uddin N, Patterson JH. Current guidelines for treatment of heart failure: 2006 update. Pharmacotherapy. 2007;27(4 Pt 2):12S-17S.