Policy Statement
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

https://doi.org/10.1016/j.cardfail.2013.02.002Get rights and content

Abstract

Background

Heart 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 Results

The 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.

Conclusions

Positive outcomes associated with clinical pharmacist activities support the value of making this resource available to HF teams.

Section snippets

Clinical Pharmacist Roles Across the Continuum of Heart Failure Care

Although each practice setting (ie, inpatient vs outpatient care) provides a unique opportunity for clinical pharmacist contributions, there are a few services that are consistent across all areas of patient care. These include early identification and prevention of adverse drug reactions and interactions, therapeutic drug monitoring, medication reconciliation, and promoting medication adherence.

Role of Pharmacist in Discharge Education

Patient education is the final, critical step in the discharge process as the patient moves from hospital care to self-care at home. Although it is clear that discharge education alone is not sufficient to lead to full retention of information, it is often an early step in the process. Clinical pharmacists can use their expertise in drug therapy to inform HF patients regarding the safe and effective use of medications. Additionally, participating in the patient’s discharge education provides

Clinical Pharmacists as Members of the Outpatient Heart Failure Team

A major focus in HF care for health systems is minimizing hospitalizations. Hospital readmission negatively affects mortality and is a primary driver of costs. Therefore, efforts to improve outpatient care are important, and clinical pharmacy services have demonstrated benefit in the outpatient HF setting.

Clinical Pharmacist on the Transplant/Mechanical Circulatory Support Team

Heart failure programs offering heart transplantation and mechanical circulatory support (MCS) as options for care rely on a multidisciplinary team approach—including cardiologists, surgeons, nurses, social workers, and clinical pharmacists—to provide effective care across the transplant continuum. With the complex pharmacokinetics of current immunosuppressive drugs, the clinical pharmacist’s expertise to identify potential drug-drug interactions and adverse events and to provide patient

Role as Educators

Clinical pharmacists are frequently involved in educational venues such as grand rounds, patient working rounds, and/or focused in-services. All medical disciplines at all levels are likely to benefit from education about pharmacokinetics and pharmacodynamics. Several national and international cardiology and transplant organizations include clinical pharmacists as active members, providing expertise on pharmacology and pharmacotherapy for specialized educational meeting symposia, white papers,

Training Requirements for Clinical Pharmacists Participating on Heart Failure Teams

As with medicine and nursing, clinical pharmacists can obtain advanced training through the completion of residencies and/or fellowships with a specialty focus in critical care, cardiology, transplantation, or ambulatory care.122 Additionally, pharmacists can document recognition of their clinical knowledge through obtaining board certification.123

The Doctor of Pharmacy (PharmD) is currently the entry-level degree for all pharmacy students in United States colleges and schools of pharmacy.124

Conclusion

Heart failure management and transplantation have long histories of successful multidisciplinary team strategies for collaboration. Multidisciplinary interventions including clinical pharmacists on inpatient, outpatient, and MCS/transplant teams have demonstrated value by improving adherence to performance measures and evidence-based drug therapies, decreasing readmission rates, identifying and preventing adverse drug events and interactions, assessing and providing solutions for barriers to

Disclosures

Robert J. DiDomenico is a consultant for F. Hoffman LaRoche.

J. Thomas Heywood has received speaking honoraria from Actelion, Medtronic, St Jude, and Thoratec; is a consultant for Actelion, Medtronic, and Thoratec; and has received research grants from Medtronic and Gambro and fellowship support from St. Jude. JoAnn Lindenfeld is a consultant for St Jude, Boston Scientific, and Abbott and has received a research grant from Zensun. J. Herbert Patterson has received speaking honoraria from Otsuka,

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    • Cited by (0)

    This paper is being simultaneously copublished in Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, Volume 33, Issue 5.

    This paper represents the opinions of the Cardiology Practice and Research Network of the American College of Clinical Pharmacy (ACCP) and the Heart Failure Society of America (HFSA). It does not necessarily represent an official ACCP or HFSA commentary, guideline, or statement of policy or position.

    See page 366 for disclosure information.

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