Despite improvements in treatment and care, mortality rates for patients with heart failure remain high, with an inpatient mortality rate of just over 10 percent and a one-year mortality rate of around 30 percent for those who survive to discharge. Almost a third of newly diagnosed patients die within a year. It is this high inpatient mortality that led to the proposal of the Acute Heart Failure National Confidential Enquiry into Patient Outcomes and Death.
The role of the clinical pharmacist is continually expanding in the area of heart failure. Pharmacists’ involvement in the clinical care of heart failure is not a new concept, but recently the role has developed national recognition.
Given that the principal treatment for heart failure is drug therapy, and often in a multimorbid and elderly population, the recognition for pharmacist input is not unexpected. Pharmacists are ideally placed with their extensive pharmaceutical knowledge and extended skills to play a significant role in the care of heart failure patients.
The National Clinical Enquiry into Patient Outcomes and Death (NCEPOD) published their Failure to Function reportin 2018, a review over a one-year period of the care received by patients who died in hospital following an admission with acute heart failure. In England and Wales there is a five-fold variation for inpatient mortality due to acute heart failure (6 to 26 percent). NCEPOD aimed to explore avoidable and remediable factors in the process of care for patients with acute heart failure admitted to hospital as an emergency who died within seven days of admission.
The high prevalence of coexisting medical problems adds to the complexity of managing patients with heart failure and pharmacists are ideally placed to help manage their care.
Overall, the case reviewers considered 44 percent of the sample to have demonstrated good practice. Almost a third showed room for improvement in clinical aspects and 12 percent had room for improvement in both clinical and organisational aspects of care. Care was less than satisfactory in 4 percent of cases. Much can be done to improve the care of patients presenting with acute heart failure.
The report generated 15 principle recommendations. Pharmacists can play a key role in the implementation of several of these.
Recommendation 1 sets out the importance of acute heart failure guidelines and what should be included. The report showed that around two-thirds of hospitals had acute heart failure guidelines in place and over 80 percent had NT-pro BNP/BNP available. However, only 18 percent of patients with a new diagnosis had an NT-pro BNP/BNP and less than 16 percent in established heart failure. Early appropriate management is key to improving patient outcomes and pharmacists should be involved in local guideline development.
All heart failure patients should have access to a heart failure multidisciplinary team which includes a healthcare professional with expertise in specialist prescribing as per Recommendation 3. This supports NICE guidance NG106. In addition, Recommendation 4 states that medications should be reviewed by a pharmacist with specialist expertise in prescribing for heart failure.
The study highlighted that the patient demographic was elderly and frail with multiple comorbidities. Clinical frailty is an independent predictor of inpatient mortality. The high prevalence of coexisting medical problems adds to the complexity of managing patients with heart failure and pharmacists are ideally placed to help manage their care.
Study reviewers assessed the treatment that patients received and identified medication related issues that should have been managed differently. Over twenty percent of patients had treatments or interventions omitted that should have been undertaken. The appropriateness of medication changes was also assessed and highlights scope for improvement through the identification of a small but substantial proportion of patients that should have been managed differently.
In total, over a quarter of patients had one or more medication issues identified. Diuretic management is the mainstay treatment to manage fluid overload in acute heart failure. Despite their frequent use, the report showed that diuretic management could have been improved in approximately one in five cases. In fact, more than a fifth of patients were given IV fluids, highlighting that prompt diagnosis and management is required by a heart failure specialist.
NCEPOD concluded that the report illustrates the complex medication decisions that are needed in heart failure patients, and further justifies the need for specialist pharmacist involvement in their care. Pharmacists’ clinical role in heart failure teams are evolving and now include diagnosis, examination, full review and prescribing in some Trusts. However, only 12 percent of hospitals have a pharmacist as a core member of the multidisciplinary team (MDT).
Trusts should review their core MDT against NCEPOD recommendations and may find a short fall in the recommended members. This provides an opportunity for pharmacy roles in heart failure to be developed. A competency framework for heart failure pharmacists has been published and may support aspiring pharmacists to achieving this.
The NCEPOD report should help drive change to improve services and patient care. It provides evidence and support for service improvement to develop the role of the pharmacist within the heart failure multidisciplinary team. Due to their expert knowledge of medicines, pharmacists can have a significant impact through specialist prescribing and management of heart failure, patient education, follow up plans and working in clinics for safe discharge and early follow up.
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Competing interest statement:
The authors declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.