3 June 2019, by Siobhan Chan
When NICE updated its advice on managing chronic heart failure in September 2018, it signalled a greater role for pharmacists from across primary and secondary care.
The institute’s recommendations highlighted the importance of the specialist multidisciplinary team (MDT) and, within that team, the inclusion of prescribing expertise.
This specialist MDT should work alongside primary care to manage heart failure patients, it said, including diagnosis, providing information, optimising treatment and starting new medicines.
It’s the first time MDT heart failure guidelines in England and Wales have called for the inclusion of experts in medicines optimisation (the safe and effective use of medicines). Until now, hospital pharmacists with a specialism in heart failure have advised specialist teams on treatment for newly diagnosed patients and reviewed complex cases, while community pharmacists engage with these patients through the New Medicine Service or Medicines Use Reviews.
SIGN guidelines also recommend that patients with heart failure are offered follow-up with an MDT, including pharmacy input into “addressing knowledge of drugs and compliance”.
Leading pharmacists agree that the profession should play an important part in heart failure management. So how can pharmacists from across different care settings contribute?
“We need to get each one of those pharmacists in the pathway – hospital, practice and community pharmacists,” says consultant pharmacist Dr Rani Khatib. “Each one contributes in a different way to the needs of patients.”
Dr Khatib is Consultant Pharmacist in Cardiology and Cardiovascular Clinical Research at Leeds Teaching Hospitals NHS Trust and a committee member for the NICE guideline. He believes that pharmacists’ specialist knowledge puts them in an ideal position to review and prescribe medications for people with heart failure.
“If you don’t review heart failure medications, you can miss opportunities to maximise benefit. You can drive excellent outcomes by having patients on the right medications with an optimised dose that is suitable for them,” he says.
Heart failure medication can affect kidney function, blood pressure and levels of salts such as potassium in the body. “There’s a potential for harm if medicines aren’t optimised, which could be serious and even fatal,” he adds.
Evidence already exists to back up pharmacists’ contribution. A programme at the Countess of Chester Hospital NHS Foundation Trust that included a pharmacist in its MDT saw the rate of readmissions fall from 16% to 11%, and more patients left hospital with the right medication.
What is heart failure?
Heart failure is characterised by the inability of the heart to pump blood around the body effectively, often due to heart muscle damage.
It is thought to affect around 920,000 people in the UK. The average age at diagnosis is 77, and patients typically have three to four comorbidities.1
The main symptoms are breathlessness, fatigue and ankle swelling, and the condition can severely limit a patient’s quality of life unless it is well managed. The pathway following diagnosis can be unpredictable and there is currently no cure.
Meanwhile, Dr Khatib is part of a virtual heart failure clinic in Leeds that has been running for close to a decade. It supports community heart failure nurses to deal with complex patients, whose multi-morbidities, polypharmacy and drug interactions can be difficult to manage. Patients with more complex medicines optimisation needs can sometimes be referred to this Advanced Medicines Optimisation clinic by nurses, GPs and cardiologists for a face-to-face review.
“My role is to lead the medicines optimisation agenda in cardiology by working collaboratively with patients and other healthcare professionals. Through research, involvement in creating innovative pathways and supporting the development of person-centred guidelines, my objective is to maximise patient benefits and reduce the burden of cardiovascular disease,” he says.
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Practice pharmacists and heart failure
Roles for pharmacists in managing heart failure extend beyond providing specialist input – pharmacists in more generalist roles have a part to play too.
NICE recommends that stable patients are reviewed by the primary care team every six months, and that reviews should include a clinical assessment, medicines review and an assessment of renal function.
The increasing numbers of pharmacists taking up roles in general practice are well positioned to help. The new GP contract in England will see the introduction of 20,000 extra primary care staff, including pharmacists, to release GPs to spend time with patients with more complex needs.
Dr Khatib says: “I can see a role for pharmacists based in practices to support GPs with this task, to do a medicines review and see if patients need any support. It relieves pressure on GPs, and uses the expertise of the pharmacist.”
An NHS Greater Glasgow & Clyde initiative saw primary care pharmacists undertake medicines reviews of heart failure patients. It led to improvements – albeit described as ‘modest’ – in the proportion of patients taking recommended medications such as ACE inhibitors and beta blockers.2
According to Paul Forsyth, one of the pharmacists who led the work, “a multidisciplinary primary care approach, involving nurses and pharmacists, may be a solution to systematically identifying, supporting and reviewing all patients with heart failure”. 3
Leeds Teaching Hospitals NHS Trust has also started a preceptorship training scheme for all pharmacists who come across patients with heart failure. In December 2018, 20 practice pharmacists were invited to learn about heart failure management.
Dr Khatib says: “We brought them to hospital, they saw how we examine patients with heart failure, how we conduct a consultation and met members of heart failure team – it’s an exposure to a real-world heart failure service in action.” He adds that the scheme was well-received and will be run again.
Community care for heart failure
Community pharmacists are also on hand to answer medicine-specific questions from heart failure patients.
Local pharmacists are often more accessible than a specialist team and often already have a good relationship with patients, Dr Khatib says. “For example, a patient may have a problem swallowing tablets, or remembering to take their medicines. This usually doesn’t require input from a specialist to resolve. Or if they have a side-effect related to heart failure medicine: community pharmacists may not feel confident to make a recommendation to change the drug, but can have a discussion with the heart failure team.”
This relies on community pharmacists feeling well-supported by specialist teams.
He adds: “If we appropriately connect and support community pharmacists, and give them access to heart failure teams, they can maximise their benefit to patients in the community.”
A research programme funded by the National Institute for Health Research is looking at medicines management in heart failure and the best way to support patients with their medication when they leave hospital.
This involves better communication between hospitals and community pharmacists, and ‘increased engagement of community pharmacists with patient care’.
This kind of innovation is crucial to pharmacists of all roles with an interest in managing heart failure, according to Dr Khatib.
“Heart failure teams span primary, secondary and community care – the service has to be seamless,” he says. “We need to be more innovative.”
- BMJ (2017). Conrad et al. Temporal trends and patterns in heart failure incidence: a population-based study of 4 million individuals
- European Heart Journal (2012). Lowrie et al. Pharmacist intervention in primary care to improve outcomes in patients with left ventricular systolic dysfunction
- British Journal of Cardiac Nursing (2014) Forsyth et al. Novel approaches to supporting heart failure patients in primary care