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Containment of heart failure hospitalizations and cost by angiotensin-converting enzyme inhibitor dosage optimization
A B Luzier1, A Forrest, S G Feuerstein
1Department of Pharmacy Practice, State University of New York at Buffalo, USA.
Insights
Clinical pharmacists optimizing angiotensin-converting enzyme (ACE) inhibitor dosing in heart failure (HF) significantly reduced rehospitalization rates and healthcare costs. This intervention improved patient outcomes within a comprehensive HF management program.
Area of Science:
- Cardiology
- Pharmacology
- Health Services Research
Background:
- Heart failure (HF) management often involves suboptimal angiotensin-converting enzyme (ACE) inhibitor therapy.
- Optimizing ACE inhibitor dosing is crucial for improving patient outcomes in systolic dysfunction.
Purpose of the Study:
- To evaluate the impact of clinical pharmacist-led ACE inhibitor optimization on rehospitalization rates and costs in heart failure patients.
- To assess the effectiveness of an HF management program incorporating pharmacist interventions.
Main Methods:
- A prospective intervention trial was conducted with patients suffering from systolic dysfunction.
- Patients were managed under an HF program with clinical pharmacist involvement in ACE inhibitor therapy and other medications, adhering to Agency for Healthcare Policy and Research guidelines.
- Patients were divided into three groups: guideline-adherent (Group A), suboptimal therapy with pharmacist recommendation acceptance (Group B), and suboptimal therapy with physician refusal (Group C).
Main Results:
- Suboptimal ACE inhibitor therapy was common (75%), often due to non-administration or inadequate dosing.
- Groups receiving pharmacist-guided ACE inhibitor optimization (A and B) showed significantly lower rehospitalization rates (31% and 35%) compared to the control group (63%) at 180 days.
- Total healthcare charges were substantially lower in the intervention groups ($5,600 and $3,800) versus the control group ($9,800).
Conclusions:
- Clinical pharmacist intervention to optimize ACE inhibitor dosing is highly effective in reducing heart failure rehospitalizations.
- This pharmacist-led approach significantly lowers the overall cost of care for heart failure patients.
- Integrating clinical pharmacists into HF management programs enhances guideline adherence and improves clinical and economic outcomes.
Abstract:
Using our model relating angiotensin-converting enzyme (ACE) inhibitor dosing and outcomes in heart failure (HF), we designed a prospective intervention trial for patients with systolic dysfunction. A clinical pharmacist initiated or titrated ACE inhibitor therapy or adjusted other medications within an HF management program based on Agency for Healthcare Policy and Research guidelines. Entry into the protocol required the approval of the attending physician. All patients received dietary, nursing, rehabilitation, social service, and clinical pharmacy consultations. Treatment conformed to Agency for Healthcare Policy and Research guidelines in 25% of patients (group A). Suboptimal therapy (75% of patients) was usually due to failure to administer an ACE inhibitor (48%) or inadequate dosing of an ACE inhibitor (46%). In 62% of suboptimal cases, the attending physician agreed to follow the clinical pharmacist's recommendations (group B). Patients of physicians who declined pharmacist intervention served as a negative control (group C). On admission, mean enalapril-equivalent daily doses in groups A, B, and C were 30, 4, and 6 mg, respectively, and at discharge, 36, 18, and 6 mg, respectively. At 180 days, rehospitalization frequency and total charges were lower in groups A (31% and $5,600) and B (35% and $3,800) than in group C (63% [p <0.004] and $9,800 [p <0.04]). Thus, optimization of ACE inhibitor doses by a clinical pharmacist can greatly improve rehospitalization rates and significantly lower cost of care in an HF management program.