Clinical Investigation
Negative Clinical Outcomes Associated With Drug-Related Problems in Heart Failure (HF) Outpatients: Impact of a Pharmacist in a Multidisciplinary HF Clinic

https://doi.org/10.1016/j.cardfail.2010.10.009Get rights and content

Abstract

Background

Drug-related negative outcomes (DNOs) are health problems that patients experience due to drug use or nonuse. Heart failure (HF) patients are at high risk of experiencing DNOs owing to polypharmacy, comorbidities, and age.

Methods and Results

Ninety-seven consecutive HF patients were enrolled and followed for 6 months. A pharmacist, integrated within a multidisciplinary HF team, reviewed the medication of each patient to detect, resolve, and/or prevent possible DNOs, risks of developing a DNO (rDNOs) and the drug-related problems (DRPs) that are associated with them. We detected 147 DNOs/rDNOs with a mean of 1.5 ± 1.4 per patient. Among DNOs, 45% were due to a lack of a pharmacologic treatment (need for a drug) and 24% were treatments with an insufficient drug dose (quantitative ineffectiveness). Among rDNOs, 33% were due to use of an unsafe drug (nonquantitative lack of safety) and 30% to quantitative ineffectiveness. Ninety-four percent of DNOs/rDNOs were preventable, and, importantly, 5.5% were classified as clinically serious. During follow-up, pharmacist interventions solved or prevented the health problem in 83% of cases. The most frequently identified DRPs were “insufficiently treated health problem” (31%), “inadequate dose, regimen, or duration of a drug” (22%), “probability of adverse effects” (16%), and “nonadherence” (14%). A significant relationship between the number of DNOs/rDNOs and the number of drugs was found (P < .013).

Conclusions

Chronic HF outpatients have a high incidence of preventable DNOs. The inclusion of a pharmacist in multidisciplinary HF teams should be considered, because it is clinically beneficial for patients and it increases HF specialists’ awareness of DNOs, especially those beyond HF.

Section snippets

Study Population and Design

Consecutive patients were enrolled at the HF ambulatory clinic of a university hospital in Barcelona (Spain) between October 2008 and April 2009. All patients also visited their primary care physician regularly. The exclusion criterion was previous visit with the pharmacist at the HF clinic. Patient clinical status as well as biochemical and echocardiographic data were obtained upon patient enrollment. Patients were clinically followed for 6 months. A pharmacist, with a postgraduate master’s

Results

Ninety-seven HF patients were enrolled in the present study, with a mean number of medicines used of 10.2 ± 3.2. The majority of patients were in New York Heart Association functional classes II (46%) and III (52%) at inclusion. Forty-five percent of patients had preserved systolic function versus 54.6% with systolic dysfunction. However, the 2 groups were similar with a mean number of medicines taken of 10 (10.1 for preserved vs 10.6 for depressed; P = NS), and similar treatment. Table 2

Discussion

To our knowledge, this is the first study to evaluate DNOs and pharmacist interventions in HF patients. Our observations have several important clinical implications. First, HF outpatients suffer a high number of preventable drug-related morbidity events that may be solved or prevented by a pharmacist included in a multidisciplinary team. Second, those events are more related to comorbidities than to the specific HF syndrome, and they are more frequent in patients who take a higher number of

Disclosures

None.

References (31)

  • F.A. McAlister et al.

    Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials

    J Am Coll Cardiol

    (2004)
  • R.W. Troughton et al.

    Treatment of heart failure guided by plasma aminoterminal brain natriuretic peptide (N-BNP) concentrations

    Lancet

    (2000)
  • M.W. Rich

    Multidisciplinary heart failure clinics: are they effective in Canada?

    CMAJ

    (2005)
  • A. Ducharme et al.

    Impact of care at a multidisciplinary congestive heart failure clinic: a randomized trial

    CMAJ

    (2005)
  • J. Gonseth et al.

    The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta-analysis of published reports

    Eur Heart J

    (2004)
  • C.O. Phillips et al.

    Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis

    JAMA

    (2004)
  • R.L. Howard et al.

    Investigation into the reasons for preventable drug related admissions to a medical admissions unit: observational study

    Qual Saf Health Care

    (2003)
  • M.I. Baena et al.

    Medicine-related problems resulting in emergency department visits

    Eur J Clin Pharmacol

    (2006)
  • H.S. Blix et al.

    The majority of hospitalized patients have drug-related problems: results from a prospective study in general hospitals

    Eur J Clin Pharmacol

    (2004)
  • S. Varma et al.

    Pharmaceutical care of patients with congestive heart failure: interventions and outcomes

    Pharmacotherapy

    (1999)
  • K. Patel et al.

    Pharmacist participation in home health heart-failure programs

    Am J Health Sys Pharm

    (2003)
  • W.A. Gattis et al.

    Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team: results of the Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) Study

    Arch Intern Med

    (1999)
  • S.L. Koshman et al.

    Pharmacist care of patients with heart failure: a systematic review of randomized trials

    Arch Intern Med

    (2008)
  • E.E. Roughead et al.

    The effectiveness of collaborative medicine reviews in delaying time to next hospitalization for patients with heart failure in the practice setting: results of a cohort study

    Circ Heart Fail

    (2009)
  • Pharmacotherapy follow-up: the Dáder method (3rd rev.; 2005)

    Pharmacy Practice

    (2006)
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