In the U.S., about 5.1 million people have clinically manifested heart failure (HF).1 The absolute mortality rate for HF is about 50% within 5 years of diagnosis, and 1 in 9 death certificates in the U.S. list HF as a cause of death.2 Heart failure is the primary diagnosis in more than 1 million hospitalizations annually.1 Patients with HF who are at risk for all-cause rehospitalization have a 1-month readmission rate of 25%, and their median survival time decreases with each hospitalization.3,4 Heart failure is the top reason for discharge of veterans treated within the VA health care system.5
Some medications decrease morbidity and mortality in patients with systolic dysfunction.6 These medications include angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and β-blockers (BBs). Studies have demonstrated effectiveness of these medications in patients with reduced ejection fraction (EF) of less or equal to 40%. Other medications with proven success include aldosterone antagonists, hydralazine in combination with a nitrate, and digoxin. The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines provide medication recommendations based on the ACCF/AHA stages of HF and the New York Heart Association (NYHA) functional classifications, designated as guideline-directed medical therapy (GDMT).6,7 Therapeutic interventions are aimed at reducing morbidity and mortality for ACCF/AHA stage C HF. The ACCF/AHA guidelines also recommend establishing multidisciplinary HF disease management programs for patients at high risk for hospital readmission to facilitate implementation of GDMT, address different barriers to behavior change, and reduce the risk of subsequent rehospitalization for HF.6
In October 2010, the Jesse Brown VAMC (JBVAMC) in Chicago, Illinois, opened its Heart Failure Disease Management Program (HFDMP) to prevent readmissions by targeting patients discharged after HF exacerbations and arranging follow-up in the HFDMP clinic. Enrollment in the clinic is initiated when an inpatient physician places a consultation. A cardiology nurse practitioner (NP) receives the consultation and schedules an in-clinic appointment for the patient within 1 week of discharge. The patient goes to the clinic on average every 2 weeks until he or she is on a stable, optimal medication regimen and is competent in self-management. After 3 months, the patient transitions to the general cardiology clinic. This process allows the HFDMP to see new patients in need of intense care and education for HF. The multidisciplinary HFDMP began with a NP and a cardiologist and 6 months later in April 2011 added a pharmacist.
After enrolling in HFDMP, the patient can be referred to the pharmacist for independent optimization of medication therapy in the Pharmacy Medication Titration Clinic (PMTC). The PMTC at JBVAMC is different from other HF clinics in that the pharmacist has prescribing authority and can interact face-to-face with patients to titrate medications. Once a patient is on an optimal medication regimen, he or she is referred to the NP and cardiologist. The PMTC is open 4 hours twice per month and offers 30-minute time slots. The authors conducted a study of the effectiveness of face-to-face PMTC appointments within the HFDMP.
Methods
This study, approved by the institutional review board at the University of Illinois at Chicago and the research and development service at JBVAMC, was a retrospective electronic chart review of patients enrolled in the HFDMP. Study patients were aged ≥ 18 years and were enrolled in the HFDMP between April 15, 2011 and April 15, 2013. Exclusion criteria included EF higher than 40%, 1 or no appointment attended, and enrollment before April 15, 2011. There were 2 study groups: HFDMP patients enrolled in PMTC (PMTC group) and HFDMP patients not enrolled in PMTC (no-PMTC group). For 1:1 comparison, the number of patients who met the criteria for the PMTC group was used to determine the number of patients to include in the no-PMTC group. Baseline date was the date of enrollment into either HFDMP or PMTC.
Data collected at baseline included demographics, NYHA class of HF, blood pressure (BP), heart rate, ejection fraction (EF), date of HF diagnosis, number of hospitalizations for HF within previous 6 months, serum creatinine level, height, weight, comorbidities, and HF medications. Data collected at the end date included NYHA class of HF; BP; heart rate; EF; HF medications; reason for not achieving target dose of medication or GDMT; ACEI, ARB, or BB adherence, defined as 80% of medication refills 6 months after date of discharge from group; readmission for HF within 30 days and 90 days; length of stay (LOS), including bed type if readmitted; emergency department (ED) visits for HF within 6 months of date of discharge from group; and death within 6 months of date of discharge from group. Clinical GDMT was defined as reaching the maximum tolerable or target dose of each HF medication for each patient depending on clinical presentation, as recommended by the ACCF/AHA guidelines for HF.6 It incorporated NYHA class of HF, contraindications, hypotension, bradycardia, dizziness, and hyperkalemia as well as the prescribing of aldosterone antagonists, hydralazine and isosorbide dinitrate, and digoxin.