American Heart Month: A Pharmacist’s Role in Polypharmacy Management of Congestive Heart Failure Patients

February is recognized as American Heart Month, as patients are encouraged to follow the 28 Days Towards a Healthy Heart calendar to spread awareness and reduce the risk of cardiovascular disease.¹ In the middle of the month, a week is dedicated to heart failure awareness, which affects nearly 6.2 million American adults, 5 million of whom are living with congestive heart failure (CHF).^2,3

CHF results in more hospitalizations than all forms of cancer combined, and it is the most common diagnosis of hospitalized patients 65 years of age or older.⁴ Although February is the shortest month of the year, heart failure is not an acute event and accounts for complex polypharmacy that can lead to a myriad of negative patient outcomes through inappropriate prescriptions, poor adherence, adverse effects (AEs), and drug-drug interactions.⁵

Among those who are hospitalized with CHF, 17%-27% are readmitted within 30 days, with 50% being readmitted within 6 months.⁶ These high readmission rates and complicated medication regimens provide an opportunity for pharmacists to create an impactful change for this patient population.

Medication adherence is critical to prevent detrimental exacerbations and control debilitating heart failure symptoms for these patients. However, the pill burden associated with CHF is coupled with comorbid conditions such as depression, anxiety, and executive function impairment, which can further decrease medication adherence.⁶

Pharmacists can collaborate with patients to improve medication adherence, decrease polypharmacy AEs, and improve quality of life. A meta-analysis of 6665 studies from Europe, Asia, and North America found that patient-centered medication adherence interventions (medication education and disease education) by pharmacists resulted in improved adherence behavior outcome effects (ES= 0.63, p=0.049) when compared to the groups based on prescriber-focused health care behavior (ES= -0.12, p < 0.001).⁷

Moreover, a small, randomized, control trial studying pharmacist-led medication assessments (medication-condition matching chart via START criteria, medication underuse, and need for deprescribing via STOPP criteria) showed that 100% of participants reported a reduction in AEs likely attributed to polypharmacy and potentially inappropriate medication use.⁸ These decreased AEs and increased patient education can improve patients’ quality of life and further strengthen the practice of patient-centered care.

In addition to negative health outcomes, poorly controlled CHF accounts for nearly $30.7 billion in national health care costs.³ Pharmacists adopting the role of managing unnecessary pill burden through proper medication reconciliation and successful transitions of care has proven to reduce these exponential health care costs.

A coordinated interdisciplinary team of pharmacists partnering with ambulatory physicians for medication therapy management programs of pill burden disease states, such as CHF, resulted in decreased health care costs (63.2% yearly inpatient savings) with a benefit-to-cost ratio of 3.51:1 for the 16-month implementation period.⁹ The cost savings were a result of decreased total patient medical expenses due to lessening the pill burden by deprescribing inappropriate agents along with increased patient education resulting in hospitalization preventions from improved medication adherence.

Approximately 30%-50% of CHF hospital admissions are preventable if patients can afford to purchase and remember their monthly medications.10 Treatment guidelines for CHF can require 5-10 medications upon hospital discharge with an average monthly outpatient medication cost of $340 for patients who only have CHF; this number increases significantly to $730 per month for patients with CHF who also have chronic obstructive pulmonary disease and diabetes mellitus.¹⁰

The increased medication costs are parallel to the increased frequency of daily medications needed for CHF management (average 10.1 doses per day).¹¹ These numbers can leave patients feeling overwhelmed and alone.

Pharmacists can aid by finding manufacturer coupons and following up with uncontrolled patients. Numerous studies exploring implementation of pharmacy-led transition of care programs showed that receipt of a follow-up phone call from the care-transition pharmacist within 72 hours after discharge led to a significantly lower overall 30-day acute care services use rate of 22% (vs 42% for those who did not receive a phone call; P = 0.01) and a 48% lower likelihood of requirement for acute-care services within 30 days of discharge (risk ratio = 0.52; 95% confidence interval [CI] 0.33–0.82).¹²

The complexity of CHF management provides many opportunities for pharmacists to adopt impactful roles in these patients’ lives through medication therapy management, patient education, interdisciplinary collaboration, and coordinated transition of care. By and large, American Heart Month is another example of the essential and valuable position that pharmacists hold in improving health care outcomes and optimizing patient-centered care.

Resources

1. American Heart Month [Internet]. National Heart Lung and Blood Institute. U.S. Department of Health and Human Services; 2022 [cited 2022Feb1]. Available from: https://www.nhlbi.nih.gov/education/american-heart-month
2. Heart Failure Awareness Week 2022 [Internet]. Heart Failure Society of America. [cited 2022Feb1]. Available from: https://hfsa.org/heart-failure-awareness-week-2022
3. Heart Failure [Internet]. Centers for Disease Control and Prevention; 2020 [cited 2022Feb1]. Available from: https://www.cdc.gov/heartdisease/heart_failure.htm
4. Heart Failure Statistics [Internet]. www.emoryhealthcare.org. Emory Healthcare; [cited 2022Feb1]. Available from: https://www.emoryhealthcare.org/heart-vascular/heart-failure.html
5. Mastromarino V, Casenghi M, Testa M, Gabriele E, Coluccia R, Rubattu S, Volpe M. Polypharmacy in heart failure patients. Curr Heart Fail Rep. 2014 Jun;11(2):212-9. doi: 10.1007/s11897-014-0186-8. PMID: 24493574.
6. Toback M, Clark N. Strategies to improve self-management in heart failure patients. Contemp Nurse. 2017 Feb;53(1):105-120. doi: 10.1080/10376178.2017.1290537. Epub 2017 Feb 19. PMID: 28151071.
7. Ruppar TM, Delgado JM, Temple J. Medication adherence interventions for heart failure patients: A meta-analysis. Eur J Cardiovasc Nurs. 2015 Oct;14(5):395-404. doi: 10.1177/1474515115571213. Epub 2015 Feb 10. PMID: 25669661.
8. Whitman A, DeGregory K, Morris A, Mohile S, Ramsdale E. Pharmacist-led medication assessment and deprescribing intervention for older adults with cancer and polypharmacy: a pilot study. Support Care Cancer. 2018 Dec;26(12):4105-4113. doi: 10.1007/s00520-018-4281-3. Epub 2018 Jun 4. PMID: 29869294; PMCID: PMC6204077.
9. Lin HW, Lin CH, Chang CK, Chou CY, Yu IW, Lin CC, Li TC, Li CI, Hsieh YW. Economic outcomes of pharmacist-physician medication therapy management for polypharmacy elderly: A prospective, randomized, controlled trial. J Formos Med Assoc. 2018 Mar;117(3):235-243. doi: 10.1016/j.jfma.2017.04.017. Epub 2017 May 23. PMID: 28549592.
10. Hussey LC, Hardin S, Blanchette C. Outpatient costs of medications for patients with chronic heart failure. Am J Crit Care. 2002 Sep;11(5):474-8. PMID: 12233973.
11. Page RL, O’Bryant CL, Cheng D, Dow TJ, Ky B, Stein CM, et al. Drugs that may cause or exacerbate heart failure. Circulation. 2016;134(6):32–69.
12. Anderson SL, Marrs JC. A Review of the Role of the Pharmacist in Heart Failure Transition of Care. Adv Ther. 2018 Mar;35(3):311-323. doi: 10.1007/s12325-018-0671-7. Epub 2018 Feb 27. PMID: 29488151; PMCID: PMC5859692