Key Points:
- Over 6 million people in the US live with heart failure (HF), but national rates of GDMT treatment remain low
- Because pharmacists can prescribe medication and often manage chronic medical conditions, the PHARM-HF A&F study aimed to determine if education alone versus a treatment audit-and-feedback (A&F) system increased the frequency of HF medication adjustments
- The A&F arm demonstrated an increase in monthly encounters and medication adjustments compared to education alone, as well as an increase in MRA adjustments
- Though there were no significant differences in other GDMT adjustment between both arms, both arms demonstrated an increase in GDMT initiation and uptitration with longer-term follow-up needed to assess additional outcomes
In the United States, over 6 million people live with heart failure (HF). Guideline-directed medical therapy (GDMT) improves outcomes among HF patients, but national rates of GDMT treatment are low. Previous studies have established that pharmacist-based HF care can increase prescription of and adherence to GDMT. The Veterans Affairs Healthcare System (VA) is staffed by pharmacists in primary care clinics that can prescribe medication and often manage hypertension or diabetes. Veterans with HF treated with pharmacists have been demonstrated to be on more optimal medical therapy, but only 10% of this group is treated by pharmacists. This is thought to be due to barriers that include lack of HF management experience as well as lack of focus on this specific disease. In this context, the PHARM-HF A&F study aimed to determine if giving pharmacists data on how often they adjust HF medication therapy compared with their peers as well as HF education increases the frequency of HF medication adjustments compared to HF education alone.
The PHARM-HF A&F study was a single center study based in the Sierra Nevada VA system with 120 primary care pharmacists enrolled. In the first arm of randomization, 62 patients were allocated to usual care with HF education, while 58 patients were allocated to the intervention arm, which included an audit of pharmacists’ HF medical treatment and subsequent feedback along with education. The 58 patients in the intervention arm were further randomized, with 28 patients allocated to an arm without targeted patient reports on HF medical management and 30 patients allocated to an arm with such reports. The education and training intervention (in both groups) was composed of HF therapy treatment education, including best practice documents, medication titration protocols, pharmacist educational sessions, and Q&A on HF management. The audit and feedback (A&F) intervention identified the number of HF medication treatment actions pharmacists were taking over time as well as site-level GDMT prescription rates. In addition, the patient-specific feedback branch of the intervention arm was alerted to seven eligible potential patients monthly and given specific patients to prioritize.
With regard to change in HF monthly encounters, the education arm demonstrated an increase by 0.5 (95% CI: 0.0, 0.9), and the A&F arms demonstrate an additional increase by 1.2 (95% CI: 0.8, 1.7), though there was no significant difference between the A&F+ and A&F arms (95% CI: -0.6, 0.8). Regarding change in HF medication encounters, the education arm demonstrated an increase in monthly encounters by 0.2 (95% CI: 0.1, 0.4) and the A&F arm showed an additional increase in 0.2 (95% CI: 0.1, 0.4). At 6 months, the only significant difference in medication initiation or uptitration was among mineralocorticoid receptor antagonists (MRA), with an increase in 9.2% among the education arm and an increase in 11.6% among the A&F arm (p < 0.01). There was an increase in beta-blocker (BB) (23.4% total), renin-angiotensin-aldosterone (RAAS) inhibitors (22.6% total), and SGLT2-inhibitors (19.4% total) initiation and uptitration across all arms, but no significant difference was seen across study arms.
The investigators conclude that both education alone as well as A&F demonstrated an increase in GDMT utilization, with a small but notable increase in MRAs in the A&F arm. They note that this is significant as MRAs are historically the most underprescribed GDMT. Otherwise, both arms demonstrated increases in HF medication management over the course of the study, with a small increase among the A&F arm compared to education alone. In addition to these results, the investigators will assess the long-term outcomes beyond the 6-month course of the study, including impact on medication rates, qualitative interviews with pharmacists, and the lack of impact of the patient-specific feedback intervention.