Shah Shivani P, Dixit Neal M, Mendoza Keana, Entabi Rana, Meymandi Sheba, Balady-Bouziane Nadrine, Chan Patrick
J Am Pharm Assoc (2003). 2022 Mar-Apr;62(2):575-579.e2. doi: 10.1016/j.japh.2021.11.012. Epub 2021 Nov 14.
Management of heart failure with reduced ejection fraction (HFrEF) requires timely initiation and up-titration of guideline-directed medical therapy (GDMT). In safety-net hospitals (SNHs), limited health care staff and resources make achievement of optimal medical therapy challenging. Recent studies have shown that medication titration performed by clinical pharmacists can improve outcomes in ambulatory management of HFrEF; however, the impact of these services within an SNH remains unknown.
Determine the impact of integrating clinical pharmacists into a heart failure (HF) clinic on initiation and titration of GDMT within an SNH.
We performed a single-center retrospective cohort study of patients with HFrEF treated in an ambulatory HF medication titration clinic within an SNH before and after clinical pharmacist integration. Primary outcomes included dose optimization rates of GDMT, time between clinic visits, and time to optimization of GDMT. Exploratory secondary outcomes were all-cause, HF, and cardiovascular acute care service utilization and all-cause, HF, and cardiovascular mortality before and after clinical pharmacist integration up to 6 months after initial clinic visit.
A total of 153 patients with HFrEF were treated. Baseline characteristics in the pre- and postintervention groups were comparable. After clinical pharmacist integration, there was a statistically significant improvement in optimization of renin-angiotensin-aldosterone system inhibitor or hydralazine-nitrate equivalent (82% vs. 94%, P = 0.02). Dose optimization rates of beta-blockers (90% vs. 83%, P = 0.22) and mineralocorticoid receptor antagonists (57% vs. 57%, P > 0.99) were unchanged. There was a statistically significant reduction in mean time between clinic visits (26 vs. 14 days, P < 0.001) and in mean time to optimization of GDMT (88 vs. 45 days, P = 0.002). All-cause mortality was reduced (13% vs. 2%, P = 0.01).
In SNHs, where limited health care staff and resources present as barriers to timely initiation and titration of GDMT, integration of clinical pharmacists into HF clinics can serve as a practical solution.
射血分数降低的心力衰竭（HFrEF）的管理需要及时启动并滴定指南指导的药物治疗（GDMT）。在安全网医院（SNHs）中，医疗保健人员和资源有限，实现最佳药物治疗具有挑战性。最近的研究表明，临床药师进行的药物滴定可以改善HFrEF门诊管理的结局；然而，这些服务在安全网医院中的影响仍然未知。
确定在安全网医院中将临床药师纳入心力衰竭（HF）门诊对GDMT启动和滴定的影响。
我们对安全网医院内一家门诊HF药物滴定诊所中临床药师纳入前后治疗的HFrEF患者进行了单中心回顾性队列研究。主要结局包括GDMT的剂量优化率、门诊就诊间隔时间以及GDMT优化时间。探索性次要结局是初始门诊就诊后长达6个月内临床药师纳入前后的全因、HF和心血管急性护理服务利用率以及全因、HF和心血管死亡率。
共治疗了153例HFrEF患者。干预前和干预后组的基线特征具有可比性。临床药师纳入后，肾素 - 血管紧张素 - 醛固酮系统抑制剂或肼屈嗪 - 硝酸盐等效物的优化有统计学显著改善（82%对94%，P = 0.02）。β受体阻滞剂（90%对83%，P = 0.22）和盐皮质激素受体拮抗剂（57%对57%，P > 0.99）的剂量优化率未改变。门诊就诊平均间隔时间（26天对14天，P < 0.001）和GDMT优化平均时间（88天对45天，P = 0.002）有统计学显著缩短。全因死亡率降低（13%对2%，P = 0.01）。
在安全网医院中，医疗保健人员和资源有限是及时启动和滴定GDMT的障碍，将临床药师纳入HF门诊可以作为一种切实可行的解决方案。
