Active feedback improves pharmacist participation in heart failure treatment

Pharmacists who received active feedback about their heart failure patients increased the frequency of their patient interactions and prescribed more heart failure medication adjustments, according to late-breaking science presented today at the American Heart Association's Scientific Sessions 2024. The meeting, Nov. 16-18, 2024, in Chicago, is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science.

Heart failure is a major public health burden and more than 8 million adults in the U.S. are expected to have the condition by the year 2035, according to the American Heart Association. In this study, called the PHARM-HF A&F Study, researchers gave Veterans Health Administration (VHA) primary care pharmacists educational resources and feedback about the care they were providing to heart failure patients, to assess whether this could improve patient care by improving heart failure medication treatment.

Primary care pharmacists in the Veterans Health Administration System are embedded within primary care panels and work closely with primary care physicians and nurses on medication management for patients.

In the VHA, primary care pharmacists can provide medication counseling, necessary monitoring and they can independently prescribe indicated therapies. They are empowered to identify individuals who would benefit from guideline-recommended treatments that are not being prescribed, such as heart failure medical therapy, and permitted to contact the patients to initiate therapy."

Alexander Tarlochan Singh Sandhu, M.D., M.S., lead study author, cardiologist specializing in heart failure at Stanford University in Palo Alto, California

During the study evaluation period between January and May 2024, 120 primary care pharmacists responsible for more than 7,000 heart failure patients were randomly assigned to one of three study groups. The groups were 1) the control group, who received educational materials about treatment protocols, monthly webinars and a database of frequently asked questions about heart failure management; 2) an audit and feedback group, who received educational materials and monthly audit and feedback emails nudging heart failure medication management; and 3) a third group of pharmacists who received educational materials, monthly audit and feedback emails, plus targeted information listing patients with heart failure who had potential for improvement with their medication regimen.

Before the study period, each pharmacist averaged two patient visits per month that included heart failure care and 0.4 patient visits per month that included an adjustment of heart failure medication.

Preliminary findings show both groups had increases in their frequency of heart failure management. Pharmacists who were audited and received feedback had an additional significant increase in the frequency in which they managed heart failure patients, with 1.2 more visits with patients per month and more heart failure medication adjustments, with 0.2 more visits per month compared with the education-only arm. However, adding access to patient-specific information in addition to the audits and feedback did not result in any improved outcomes. Receiving monthly audit and feedback emails led to a small, but significant, increase in the frequency of prescribing a mineralocorticoid receptor antagonist medication. Historically, a mineralocorticoid receptor antagonist is the most under-prescribed component of heart failure medication therapy.

"We found that when pharmacists participated in the audit and feedback group, they were more likely to identify patients who would benefit from medication adjustment, set up new appointments with patients to adjust heart failure medications and adjust heart failure medication therapy during appointments, thus, potentially leading to improved heart failure management and better patient outcomes," Sandhu said.

"This shows one approach to increasing the use of pharmacists to improve heart failure medication use, and it may also be applicable to other chronic diseases," he added. "This is a major opportunity to improve health for more patients, especially in a system like the Veterans Affairs Healthcare System with a large, robust network of pharmacists nationwide."

A strength of this study was its practical approach and that it is an intervention that is highly scalable, Sandhu said. A major limitation was that the patient-specific data provided to pharmacists was not restricted to their own roster of patients.

"The main surprise was that patient-specific data did not lead to an additional increase in heart failure medication adjustment," Sandhu said. "We know pharmacists can help improve medical therapy for patients with heart failure, however, most pharmacists are not providing heart failure care even when they are allowed to."

The next step in research is to evaluate longer-term impact on medication rates, to conduct qualitative interviews with the pharmacists to better understand what worked for them and how the intervention could be improved, and why the patient-specific information was not useful. Researchers plan to adapt and evaluate this intervention in more VHA locations next year.

Study background and details:

• The PHARM-HF A&F Study included 120 Veterans Health Administration primary care pharmacists deemed eligible to participate in the program for their roster of patients with heart failure in Northern and Central California, Nevada, Hawaii, American Samoa and Guam.
• The pharmacists were responsible for 7,224 adults with heart failure under the care of 337 primary care teams.
• Patients were a median age of 75, and 98% were men.
• 65% of participants were white adults, while 14% were Black adults, 5% were Asian adults, 1% were Native American or Alaska Native people, 4% were Pacific Islander adults and race was unknown for 11%. Race was mostly self-reported by study participants rather than selected by clinicians.
• 86% of the participants self-identified as non-Hispanic, 8% as Hispanic and for 6%, ethnicity was unknown. Ethnicity was mostly self-reported by participants rather than selected by clinicians.

Co-authors and disclosure information are listed in the abstract. The study was funded by the American Heart Association Rural PRO-CARE Health Equity Research Network and the Veterans Affairs QUERI Program.