Optimising Medication in patients with Chronic Heart Failure

The project was designed to improve heart failure (HF) management in primary care across two boroughs in South London through a pharmacist-led but multi-disciplinary approach to patient care. Pilot work in one CCG (Lambeth) identified that sub-optimal medicines use was multifactorial, but specifically identified:

• lack of GP confidence in managing HF
• lack of knowledge of the impact of core therapies on outcome, and the importance of dose optimisation
• clinical inertia to address sub-optimal medicines use in apparently stable HF patients
• concerns about managing HF in patients with multiple co-morbidities

With this in mind, offering practices specialist pharmacist support to address deficiencies in HF care was considered an appropriate solution.

HF is a significant cause of mortality and morbidity with a high rate of hospital admission, and represents a significant burden to patients and the NHS. There is robust data to support medicines use to reduce HF mortality and hospitalisation and clear guidance from NICE recommending ACEI and beta-blockers as core therapies for this condition. NICE Quality Standard for HF emphasise that these drugs should be increased to the maximum licensed or tolerated dose to ensure outcomes are optimised. Analysis of Quality and Outcomes Framework (QOF 2012) data demonstrates that nationally, only 45% of patients on the HF registers are on ACEI/ARB with only 26% on an ACEI / ARB and a beta-blocker. This clearly indicates sub-optimal medicines use in patients with HF and an opportunity for pharmacist input to improve care. Locally, HF accounted for 258 unplanned admissions within the CCG in 2011/12. HF is a frequent reason for hospital admission in Southwark, with 258 admissions in 2011/12 (SEPHO CVD profiles). Once admitted, patients with HF tend to have extended length of stay and are represent a significant financial burden to the CCG.

National data shows that 50% of HF patients admitted to hospital either readmit to hospital or die within a year of the admission (NICOR HF Audit website 2014) and almost 1 in 7 patients admitted to hospital with HF die during that admission or within 30 days of discharge (national HF Audit 2012/13).

Current provision of HF services in the UK focuses primarily on patients with a new diagnosis or those with known HF who have had a recent acute hospital admission. This represents only a small proportion of patients on the practice HF registers. Most HF patients are managed solely within general practice, hence the project was designed to support and educate GPs to improve the management of their own patients.

The project was designed to improve heart failure (HF) management in primary care across two boroughs in South London through a pharmacist-led but multi-disciplinary approach to patient care. This project formed part of the medicines optimisation plan for 2013/2014. The project was undertaken in a number of phases, with the practice initially collating individual patient data on a standardised proforma, for all patients on the HF register. A 'virtual clinic' was then arranged with a specialist clinical pharmacist (either the HF pharmacist or consultant CVD pharmacist). In this virtual clinic, the practice staff (which may include GPs, practice nurses, practice pharmacists and practice managers) met with the specialist pharmacist and each patient on the HF register was discussed in detail, informed by the data collected by the practice prior to the clinic.

These discussions:

• Reviewed the diagnosis of HF to confirm the type of HF and ensure this had been correctly coded on the GP database.
• Reviewed the current treatment of HF focusing primarily on ACE inhibitor (ACEI) and beta-blocker (BB) use in patients with HF due to left ventricular systolic dysfunction (LVSD), as well as use of other drug therapies for HF such as diuretics, aldosterone antagonists and ivabradine.
• Reviewed the management of other cardiovascular issues in these HF patients, such as blood pressure management, lipid management and anticoagulation in atrial fibrillation.
• Reviewed whether the relevant patient monitoring was being undertaken, including checking blood pressure (BP) and heart rate (HR) and monitoring renal function.
• Tackled GP reluctance to optimise doses through education and support to overcome barriers.

For each patient, the pharmacists made recommendations to address any issues highlighted by the discussion and agreed an action plan for the practice to follow. Practices were incentivised through the CCG medicines management plan to deliver on the action plans, and were paid on submission of outcomes at the end of the year. This project was delivered over a 6 month period and was achieved because the project was designed to maximise use of specialist pharmacist time and expertise, with each virtual clinic taking between 2 to 3 hours to complete.

From one borough with 45 practices, in which 35 practices engaged in the project, data on 872 patients was collated, representing 62% of the patients on the CCG HF register of 1406 patients. The pharmacist made 955 recommendations:

• 345 read code changes suggested, the most frequent being to add the read code for LVSD (208; 60%). These changes improved the accuracy of patient records, e.g. by not labelling the patient with HF when they do not have it. It also ensures that the GP computer system reminds the clinician to start ACEI and BB in LVSD patients in line with the evidence base.
• 69 patients were identified on the HF with an unclear diagnosis requiring clarification
• 357 clinical interventions were suggested by the pharmacist during the virtual clinics. These were mainly optimising medication in LVSD patients, but did include other clinical interventions in non-LVSD patients.
  For LVSD patients:
• 16 initiations of ACEI and 68 dose titrations of ACEI
• 17 initiations of BB, 85 dose titrations of BB and 10 patients switched to a licensed BB
• 37 other prescribing recommendations for HF
• 36 other prescribing recommendations for other CV issues
• 38 monitoring recommendations
• 184 recommendations were made regarding patient referral or follow up. Just 43% of the LVSD patients (207 patients) were already on maximum daily doses or maximum tolerated doses of a suitable ACEI/ARB and BB.

Practices were asked to report back their learning outcomes and devise some action points after the virtual clinic. Therapeutic learning points included greater understanding of therapy goals, 'start low go slow' uptitration of BB, appreciation that COPD is not a contraindication to BB use, learning what the preferred agents were and their maximum daily doses, confidence that uptitration can occur with low BP and indeed that all patients with LVSD should be uptitrated whether they have hypertension or not.

Internal practice process changes to improve patient care included prioritising community HF communication for GP actioning and automatic booking of recently discharged cardiovascular patients for GP review to allow swift uptitration. One practice assigned a HF lead role to one of the GPs who would review all echoes and code patients appropriately, and continue to proactively review patients on the HF register going forward. Another now aims to ensure that all HF patients are seen by their regular GP wherever possible.

This project progressed from a pilot phase in 2012/13 to a full borough rollout in 2013/14 and the HF model has also now been implemented in two other South London boroughs, with a third developing a similar programme.

Locally, the pharmacist-led virtual clinic model has been used to support practices in the management of patients with hypertension and plans are being developed to utilise the skills of anticoagulant pharmacists to undertake virtual clinic reviews for patients with atrial fibrillation to improve the uptake of anticoagulation. There is scope for the pharmacist-led virtual clinic model to be rolled out across other specialities and patient groups (e.g. respiratory patients, complex elderly) according to local priorities. The virtual clinic model, focusing on the management of their own patients, was well received by practices and provided the opportunity for tailored training and education. Efforts must be made to engage the practices early to ensure they have sufficient time to implement the actions from the virtual clinic.

There is a need to up-skill staff working in general practice, particularly in the management of chronic diseases. Specialist pharmacist support, utilising a virtual clinic model, can increase the confidence of GPs to initiate and up titrate core HF therapies in line with the evidence base. The strengths of this project were in ensuring GP engagement, maximising specialist clinical pharmacists input focusing on implementation of NICE guidance, educating practitioners on optimal medicines use for HF to improve future practice, and encouraging better integrated care for patients with improved links between general practice and specialist services.