Implementation and evaluation of pharmacist-led heart failure diagnostic and guideline directed medication therapies clinic.

BACKGROUND: Timely diagnosis of heart failure (HF) and rapid optimisation of guideline-directed medication therapy (GDMT) improves patients qualities of life, reducing mortality and morbidity. Previous papers describe the role of pharmacists in medication optimisation, but not in the diagnosis of HF. AIM: To describe the development, implementation, and evaluation of pharmacist-led heart failure clinics with respect to time from referral to diagnosis, time from diagnosis to first review with a specialist, and the proportion receiving optimal GDMT 180 days after diagnosis. SETTING: Community outpatient clinics in rural west Wales, United Kingdom. DEVELOPMENT: Two experienced non-medical prescribing pharmacists, one of whom had additional diagnostic qualifications in cardiology, delivered the clinic. IMPLEMENTATION: Patients referred with suspected HF were risk-stratified to urgent (within 14 days of referral) or routine (within 42 days) review, based on natriuretic peptide levels. Patients attended the clinic for assessment, including physical examination, electrocardiogram, and echocardiogram. Those with HF with reduced ejection fraction were initiated on drug treatment and referred to the follow-up pharmacist-led GDMT clinic. EVALUATION: A sample of 100 patients was evaluated (50 from pre-existing and 50 from new service). Median time from referral to diagnosis reduced from 61 days (IQR 47-115) to 16 days (IQR 10.5-27.5) for urgent and 19 days (IQR 11.5-33) for routine. Median time to first appointment following diagnosis reduced from 54 days (IQR 36-60.5) to 14 days (IQR 9.75-28.75) (p value < 0.0001), and proportion of patients achieving GDMT at 180 days following diagnosis improved from 24 to 86% (p value < 0.0001). CONCLUSION: This pharmacist HF diagnostic clinic and medication optimisation clinic improved time to diagnosis, time to first specialist review, and proportion of patients' achieving GDMT optimisation in a rural healthcare setting.

Predictors of confidence in research: a cross-sectional survey of pharmacists in the north of England.

OBJECTIVE: Pharmacist-led research is key to optimizing medicines use and improving pharmacy services, yet it is not yet widely embedded into careers. This study aims to identify predictors of confidence in meeting the research learning outcomes in the Royal Pharmaceutical Society (RPS) Post-Registration Foundation and Core Advanced curricula, to provide targeted recommendations for building research capability and capacity within the profession. METHODS: The study was a cross-sectional electronic survey, distributed to eligible pharmacists in March 2023 (n = 253). The survey gathered demographic information, research experience, and self-reported confidence in meeting the research learning outcomes in the RPS Post-Registration Foundation and Core Advanced curricula. Pre-determined independent variables were analysed using two binomial logistic regression models (one per curriculum) to identify predictors of the dichotomous variable: confidence with meeting all research learning outcomes in that curriculum. KEY FINDINGS: Participants were more likely to self-report as confident (versus not confident) with meeting all research learning outcomes in a curriculum if they had recent experience (within the previous 12 months) of research or research-related activities, held a postgraduate research qualification, had undertaken research training outside of a postgraduate qualification, discussed research in their appraisal, or worked in the hospital sector. Conversely, male gender, years practicing, and protected time for research did not predict confidence. CONCLUSION: A targeted approach, including improving access to research methods training, experience-based learning, mentorship, and linking research projects to key organizational objectives, could be the key to developing research capability and capacity across all sectors and career stages.

Loop diuretic utilisation with or without heart failure: impact on prognosis.

BACKGROUND & AIMS: Many patients are prescribed loop diuretics without a diagnostic record of heart failure. Little is known about their characteristics and prognosis. METHODS: Glasgow regional health records (2009-2016) were obtained for adults with cardiovascular disease or taking loop diuretics. Outcomes were investigated using Cox models with hazard ratios adjusted for age, sex, socioeconomic deprivation, and co-morbid disease (adjHR). RESULTS: Of 198,898 patients (median age 65 years; 55% women), 161,935 (81%) neither took loop diuretics nor had a diagnostic record of heart failure (reference group), 23,963 (12%) were taking loop diuretics but had no heart failure recorded, 7,844 (4%) had heart failure recorded and took loop diuretics and 5,156 (3%) had heart failure recorded but were not receiving loop diuretics.Five-year mortality was only slightly higher for heart failure in absence of loop diuretics (22%; adjHR: 1.2 [95% CI 1.1-1.3]), substantially higher for those taking loop diuretics with no heart failure recorded (40%; adjHR: 1.8 [95% CI 1.7-1.8]) and highest for heart failure treated with loop diuretics (52%; adjHR: 2.2 [95% CI 2.0-2.2]). CONCLUSIONS: For patients with cardiovascular disease, many are prescribed loop diuretics without a diagnosis of heart failure being recorded. Mortality is more strongly associated with loop diuretic use than with a heart failure record. The diagnosis of heart failure may be often missed, or loop diuretic use is associated with other conditions with a prognosis similar to heart failure, or inappropriate loop diuretic use increases mortality; all might be true.

A Pharmacist Clinician Model as part of a collaborative clinical workforce: A philosophical critique.

The term 'clinician' is not reserved for any healthcare professional group. However, there is a general acceptance that a clinician would have the knowledge, skills and behaviours to enable them to clinically assess and manage a patient autonomously. The expectation, in a modern collaborative healthcare system, is that this work would be completed as a part of a planned and integrated multi-disciplinary care delivery structure, where any given clinician delivers a devolved element of that patient's care. Forthcoming changes to regulation and professional development pathways in the UK will have a profound impact on pharmacist professional identity and practice. From 2026, all new UK pharmacist registrants will have full independent prescribing rights. A paradigm shift is expected to enable the development of a Pharmacist Clinician Model, incorporating pharmaceutical care needs with wider clinical assessment, diagnostic, and clinical management responsibilities. Consideration is given to this model and its implications. Changes to regulation, policy, education, and the governance required to deliver safe and effective pharmacist clinicians are outlined. A philosophical critique on the nature of being a clinician, and the differentiation of pharmacist clinician roles compared to other healthcare professions, is given. A further examination of the projected risks and expected benefits of this transformative practice model are then explored.

Patient Experiences of Community Pharmacy Medication Supply and Medicines Reconciliation at Hospital Discharge: A Pilot Qualitative Study.

(1) Background: As part of the Scottish Government's five-year recovery plan to address the backlog in NHS care following the COVID-19 pandemic, community pharmacies in Scotland are planned to provide a Hospital Discharge Medicines Supply and Medicines Reconciliation Service. We aimed to qualitatively explore patients' experiences with this new service. (2) Method: Adult patients (≥18 years age) who consented to participate in the Community Pharmacy Hospital Discharge and Medicines Reconciliation Service were invited for an interview within 21 days of discharge from hospital. Qualitative, one-to-one, semi-structured patient interviews were conducted by telephone and audio-recorded using Microsoft Teams®. The interview audio recordings were transcribed verbatim and underwent thematic analysis. (3) Results: Twelve patients were interviewed, evenly split by sex and with a median age of 62 years (range 36 to 88 years). Our analysis generated main five themes: patient engagement, stakeholder communication, practical factors, human factors, and comparative experiences. Many of these were interdependent. (4) Conclusions: Patients appreciated that the service ensured a quicker discharge from hospital. Good stakeholder communication, practical factors (including choice, location, and the realities of obtaining their medication from the community pharmacy), and a pre-existing and trusted relationship in their usual community pharmacy were the key factors that regulated the patient experience. Generally, patients were positive about the introduction of this new service. However, the lack of a previous relationship or trust with a community pharmacy, and previous experiences with medication supply problems were factors which had the potential to negatively impact patient experiences.

A qualitative exploration of how pharmacy professionals in primary care utilise planned protected development time.

Background: With patients developing more complex healthcare and medicine needs, it is imperative pharmacy professionals enhance their knowledge and skills to enable an advanced level of pharmaceutical practice, improving service provision and supporting patient care. The UK Royal Pharmaceutical Society (RPS) is urging employers to incorporate protected time within the working week to facilitate this development. Currently protected development time (PDT) is not well established within the pharmacy profession and there is little qualitative data available about the utility of this. Objective: To explore how pharmacy professionals in primary care currently utilise planned protected 'development time' and their perception of this. Methods: One-to-one semi-structured interviews were conducted between February and March 2023 via Microsoft Teams® with pharmacists, pharmacy technicians (PTs) and pharmacy support workers (PSWs), working in a large Health board area in Scotland who had established PDT since August 2021. Interview recordings were transcribed verbatim and analysed using an inductive thematic framework approach. Results: Interviews were conducted with 13 participants (12 female); 6 pharmacists, 5 PTs and 2 PSWs. Five core themes were derived from the data: logistics, competing priorities, methods for development, inequalities and benefits. Participants utility of PDT was variable, most focused on self-development to improve clinical knowledge however, supporting the development of others often taking precedence. Disparities in utility and inequity of protection from service delivery were highlighted. All participants befitted from PDT reporting a self-assessed improvement in confidence and competence. Conclusion: The experience of participants who had PDT was typically perceived as positive including supporting development and improving wellbeing however, it fostered inequalities which needs addressing. Educational input is required to provide direction for development across all four pillars of professional practice; clinical practice, leadership, education and research, promoting advanced practice. Further research is required to assess the impact of PDT on health outcomes of the local population.

Multiprofessional heart failure self-development framework.

OBJECTIVE: Heart failure remains a key public health priority across the globe. The median age of people with heart failure admitted to hospital in the UK is 81 years old. Many such patients transcend the standard interventions that are well characterised and evidenced in guidelines, into holistic aspects surrounding frailty, rehabilitation and social care. Previous published competency frameworks in heart failure have focused on the value of doctors, nurses and pharmacists. We aimed to provide an expert consensus on the minimum heart failure-specific competencies necessary for multiple different healthcare professionals, including physiotherapists, occupational therapists, dietitians and cardiac physiologists. METHODS: The document has been developed focussing on four main parts, (1) establishing a project working group of expert professionals, (2) a literature review of previously existing published curricula and competency frameworks, (3) consensus building, which included developing a structure to the framework with ongoing review of the contents to adapt and be inclusive for each specialty and (4) write up and dissemination to widen the impact of the project. RESULTS: The final competency framework displays competencies across seven sections; knowledge (including subheadings on heart failure syndrome, diagnosis and clinical management); general skills; heart failure-specific skills; clinical autonomy; multidisciplinary team working; teaching and education; and research and development. CONCLUSION: People with heart failure can be complex and have needs that require input from a broad range of specialties. This publication focuses on the vital impact of wider multidisciplinary groups and should help define the generic core heart failure-specific competencies needed to support future pipelines of professionals, who regularly interact with and deliver care for patients with heart failure.

Medication supply at hospital discharge via community pharmacy: a quality improvement study.

BACKGROUND: Patient delays at the point of their discharge account for more than half a million additional bed days every year in Scotland, United Kingdom. Bottlenecks in discharge medication dispensing contribute to such delays. AIM: To test whether the discharge process could be made more time-efficient by utilising community pharmacy supply of medicines on the day of discharge, rather than hospital pharmacy supply. SETTING: Glasgow Royal Infirmary, Scotland. DEVELOPMENT: Local community pharmacy staff received training and communication about each patient discharge. Pharmacies could access an immediate discharge letter (IDL) on a shared electronic record. The existing pandemic law allowed medication dispensing from this IDL, without a prescription. IMPLEMENTATION: The programme was implemented from June to November 2020, across three Plan-Do-Study-Act (PDSA) cycles. Comparisons were made between the new community pharmacy model and standard hospital model. EVALUATION: Across three PDSA cycles, in total 335 patients had community pharmacy supply compared to 376 patients eligible for hospital pharmacy supply. The median time taken from creation of the IDL to final completion was significantly lower in the new community pharmacy model compared to the hospital pharmacy model; 154 min (interquartile range (IQR) 82-272 min) vs 296 min (IQR 197-1281 min) p value < 0.000 CONCLUSION: A community pharmacy supply model compared to a standard hospital pharmacy model resulted in a median time saving of 142 min per patient. Such a time saving has the potential to deliver a transformational change in patient flow and free up hospital pharmacy staff to deliver other clinical interventions.

Holistic approach to drug therapy in a patient with heart failure.

Heart failure (HF) is a growing global public health problem affecting at least 26 million people worldwide. The evidence-based landscape for HF treatment has changed at a rapid rate over the last 30 years. International guidelines for the management of HF now recommend the use of four pillars in all patients with reduced ejection fraction: angiotensin receptor neprilysin inhibitors or ACE inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose co-transporter-2 inhibitors. Beyond the main four pillar therapies, numerous further pharmacological treatments are also available in specific patient subtypes. These armouries of drug therapy are impressive, but where does this leave us with individualised and patient-centred care? This paper reviews the common considerations needed to provide a holistic, tailored and individual approach to drug therapy in a patient with HF with reduced ejection fraction, including shared decision making, initiating and sequencing of HF pharmacotherapy, drug-related considerations, polypharmacy and adherence.

The Collaborative Care Model: Realizing healthcare values and increasing responsiveness in the pharmacy workforce.

Healthcare values are fairly ubiquitous across the globe, focusing on caring and respect, patient health, excellence in care delivery, and multi-stakeholder collaboration. Many individual pharmacists embrace these core values. However, their ability to honor these values is significantly determined by the nature of the system in which they work. The paper starts by presenting the prevailing pharmacist workforce model, the 'Atomistic' Model, in Scotland, in which core roles are typically separated into hierarchically disaggregated jobs focused on one professional 'pillar': Clinician/Practice Provider; Educator; Leader/Manager; and Researcher. This skills-segregation yields a workforce of individuals working in isolation rather than collaborating, lacking a shared purpose. Key strategic flaws include suboptimal responsiveness to population needs, inconsistency/inequity of care, erosion of professional agency, and lower job satisfaction. It is conjectured that this results from a lack of congruence between values, professional ethos, and organizational structure. 'Atomism' culminates in a syndrome of widespread professional-level cognitive dissonance. The paper contrasts this with an emerging workforce vision, the Collaborative Care Model. This new model defines a systems-first-approach, built on the principle that all jobs must include all four professional 'pillars'. Vertical skills integration, involving education and task sharing, supports sustainability and succession planning. Horizontal skills integration (across practice, leadership/management, education, and research) is included to improve responsiveness to population need and individual professional agency. The working conditions, supportive ethos, and career structure needed to make the model work are described. Moral and workforce theory are used to justify why the model may be more effective for population health, delivering greater job satisfaction for individuals and ultimately helping systematically realize healthcare values. Finally, the paper sketches the first steps needed to implement the model at the national level, starting with the operationalization of new multi-'pillar' professional curricula across the career spectrum. Potential challenges also are discussed.

Are UK pharmacists ready for consultant-level practice? A cross-sectional survey of self-assessed development needs.

OBJECTIVES: The four nations of the United Kingdom (UK) have endorsed a new curriculum and credentialing process for consultant pharmacists. This study aimed to measure the self-reported consultant-level practice development needs of pharmacists across the UK. METHODS: The study was a cross-sectional electronic survey. Inclusion criteria were: pharmacists registered to practice with the General Pharmaceutical Council; working in any professional sector across the UK; and self-identifying as already working at an advanced level of practice or in an advanced pharmacist role. Participants were asked to rate their confidence that their current practice aligns to the level described in the Royal Pharmaceutical Society Consultant Pharmacist curriculum on a 5-point Likert scale. Predictors of overall confidence with the whole curriculum were analysed using binomial regression. KEY FINDINGS: Nine hundred and forty-four pharmacists participated. Median age was 42 years; 72.6% were female. Research skills and strategic leadership skills had low self-reported confidence. Patient-Centred Care and Collaboration was the domain with the highest reported confidence. 10.2% (96/944) of participants self-reported confidence across the whole curriculum. The strongest predictors of overall confidence across the curriculum were advanced clinical practitioner qualification, research qualifications and self-identifying as a specialist. Increasing age and male gender also predicted confidence. White ethnicity and having an independent prescribing qualification negatively predicted confidence. CONCLUSION: A small minority of pharmacists self-reported confidence across the whole curriculum. A planned approach to develop research skills across the career spectrum, coupled with better identification of workplace-based experiential strategic leadership opportunities, may help deliver a larger cohort of 'consultant-ready' pharmacists.

A qualitative exploration of the enablers and barriers to the provision of outpatient clinics by hospital pharmacists.

BACKGROUND: With increasing demands on the National Health Service (NHS), Scottish Government-led pharmacy strategy has prioritised the development and expansion of outpatient services. Pharmacist-led outpatient clinics have been shown to reduce hospital admissions and improve patient outcomes. However, expanding these contemporary models of care has proved challenging, and there are few qualitative data about the factors affecting the provision of these. AIM: This study aimed to explore the enablers and barriers to hospital pharmacists providing outpatient clinics within the largest health authority in Scotland, NHS Greater Glasgow & Clyde (NHSGGC). METHOD: Between August and October 2020, one-to-one semi-structured interviews were conducted virtually using the videoconferencing platform Microsoft Teams®, with NHSGGC hospital pharmacists who did or did not provide clinics. Audio- and video-recordings of the interviews were transcribed verbatim and underwent thematic analysis. RESULTS: 16 hospital pharmacists were interviewed; 50% were clinic providers and 50% were not. Analysis generated seven themes: clinical or service need, individual factors, clinic structure and processes, additional clinical skills and training, competing priorities, macro-level pharmacy working, and external stakeholder relationships. Many of these were interdependent and had the potential to be an enabler or a barrier to clinic provision, depending on the context or individual. CONCLUSION: The enablers and barriers to hospital pharmacists providing outpatient clinics are multifaceted, incorporating individual, systematic and professional factors. The implementation of new national professional curricula may help address many of these factors, however prospective research needs to accompany this vision.

The standards of practice for delivery of polypharmacy and chronic disease medication reviews by general practice clinical pharmacists: a consensus study.

Background General practice in the UK is experiencing a crisis. Greater multidisciplinary working is a potential solution. The new general practice contract in Scotland encourages this and includes a new pharmacotherapy service to be delivered by General Practice Clinical Pharmacists (GPCPs). Consensus is lacking for the standards of practice for delivery of pharmacotherapy medication reviews (which are polypharmacy and chronic medication reviews) as part of this service. Aim To identify and validate standards of practice for polypharmacy and chronic disease medication (pharmacotherapy level 3) reviews conducted by GPCPs. Method A two-phased mixed-methods consensus methodology was used. Phase 1: An expert group of GPCPs (n = 4) and clinical pharmacist managers (n = 2) responsible for delivering the pharmacotherapy service used a Modified Nominal Group Technique to generate potential standards. Phase 2: Two-round Delphi survey involving GPCPs with ≥ 1 year of experience of working in general practice (n = 159). Results The expert group identified 44 potential standards of practice for polypharmacy and chronic disease reviews. Practicing GPCPs indicated during the Delphi phase that the 44 standards were applicable to practice. The standards of practice covered seven main categories: skills, environment, qualifications, qualities and behaviours, knowledge, process and experience. Conclusion Practicing GPCPs indicated that the standards identified by the expert group are acceptable and valid for current practice and the delivery of polypharmacy and chronic medication reviews. The application of these standards to practice may help GPCPs and general practices to ensure equitable delivery of patient care.

Polypharmacy definition and prevalence in heart failure: a systematic review.

Polypharmacy and heart failure are becoming increasingly common due to an ageing population and the rise of multimorbidity. Treating heart failure necessitates prescribing of multiple medications, in-line with national and international guidelines predisposing patients to polypharmacy. This review aims to identify how polypharmacy has been defined among heart failure patients in the literature, whether a standard definition in relation to heart failure could be identified and to describe the prevalence. The Healthcare Database Advanced Search (HDAS) was used to search EMBASE, MEDLINE, PubMed, Cinahl and PsychInfo from inception until March 2021. Articles were included of any design, in patients ≥ 18 years old, with a diagnosis of heart failure; that explicitly define and measure polypharmacy. Data were thereafter extracted and described using a narrative synthesis approach. A total of 7522 articles were identified with 22 meeting the inclusion criteria. No standard definition of polypharmacy was identified. The most common definition was that of " ≥ 5 medications." Polypharmacy prevalence was high in heart failure populations, ranging from 17.2 to 99%. Missing or heterogeneous methods for defining heart failure and poor patient cohort characterisation limited the impact of most studies. Polypharmacy, most commonly defined as ≥ 5 medications, is highly prevalent in the heart failure population. There is a need for an internationally agreed definition of polypharmacy, allowing accurate review of polypharmacy issues. Whether an arbitrary numerical cut-off is a suitable definition, rather than medication appropriateness, remains unclear. Further studies are necessary to understand the relationship between polypharmacy with specific types of heart failure and related comorbidities.

Advanced pharmacist practice: where is the United Kingdom in pursuit of this 'Brave New World'?

Pharmacy has developed many novel patient-facing roles across the globe, typically delivered through the lens of pharmaceutical care. The macro-level implementation of such interventions is, however, fraught with difficulty. At an individual-level, psychological barriers of pharmacists and their ability to deliver autonomous complex clinical care are key considerations. As the United Kingdom imminently plans to launch a new advanced pharmacist practice curriculum and credentialing process to support advanced skills development, this commentary discusses where progress to date has taken us and what other developmental, environmental and cultural changes are needed to support this. The commentary also challenges some of pharmacy's historic dogma, discusses a requirement for teaching to transcend simplistic concepts of medicines-harm, considers the need for the standardisation of clinical skills and discusses the necessity of formal advanced practice programmes and preceptorship models. It finally proposes the concept of Advanced Pharmacist Practitioners as the ultimate future vision of autonomous practice and the need for Government Policy to support their creation.

Effect of Neprilysin Inhibition on Left Ventricular Remodeling in Patients With Asymptomatic Left Ventricular Systolic Dysfunction Late After Myocardial Infarction.

BACKGROUND: Patients with left ventricular (LV) systolic dysfunction after myocardial infarction are at a high risk of developing heart failure. The addition of neprilysin inhibition to renin angiotensin system inhibition may result in greater attenuation of adverse LV remodeling as a result of increased levels of substrates for neprilysin with vasodilatory, antihypertrophic, antifibrotic, and sympatholytic effects. METHODS: We performed a prospective, multicenter, randomized, double-blind, active-comparator trial comparing sacubitril/valsartan 97/103 mg twice daily with valsartan 160 mg twice daily in patients ≥3 months after myocardial infarction with a LV ejection fraction ≤40% who were taking a renin angiotensin system inhibitor (equivalent dose of ramipril ≥2.5 mg twice daily) and a ß-blocker unless contraindicated or intolerant. Patients in New York Heart Association class ≥II or with signs and symptoms of heart failure were excluded. The primary outcome was change from baseline to 52 weeks in LV end-systolic volume index measured using cardiac magnetic resonance imaging. Secondary outcomes included other magnetic resonance imaging measurements of LV remodeling, change in NT-proBNP (N-terminal pro-B-type natriuretic peptide) and high-sensitivity cardiac troponin I, and a patient global assessment of change questionnaire. RESULTS: From July 2018 to June 2019, we randomized 93 patients with the following characteristics: mean age, 60.7±10.4 years; median time from myocardial infarction, 3.6 years (interquartile range, 1.2-7.2); mean LV ejection fraction, 36.8%±7.1%; and median NT-proBNP, 230 pg/mL (interquartile range, 124-404). Sacubitril/valsartan, compared with valsartan, did not significantly reduce LV end-systolic volume index; adjusted between-group difference, -1.9 mL/m2 (95% CI, -4.9 to 1.0); P=0.19. There were no significant between-group differences in NT-proBNP, high-sensitivity cardiac troponin I, LV end-diastolic volume index, left atrial volume index, LV ejection fraction, LV mass index, or patient global assessment of change. CONCLUSIONS: In patients with asymptomatic LV systolic dysfunction late after myocardial infarction, treatment with sacubitril/valsartan did not have a significant reverse remodeling effect compared with valsartan. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03552575.