Equal Treatment, Unequal Outcomes? Debunking the Racial Disparity in Renin Angiotensin Aldosterone System Inhibitor Associated Reduction in Heart Failure Hospitalizations.

BACKGROUND: Renin angiotensin aldosterone system inhibitors (RAASi) are a mainstay treatment in patients with heart failure with reduced ejection fraction (HFrEF) in part to prevent hospitalizations. However, whether RAAS inhibitors reduce the risk of hospitalization in Black patients is not entirely clear because enrollment of Black patients in previous clinical trials was low, and a previous meta-analysis showed a significant racial disparity: reduction in hospitalizations with an RAAS inhibitor in White patients but not Black patients. Previous studies relied on the use of self-identified race instead of genomic ancestry. Therefore, this study aimed to investigate the role of self-identified race and genomic ancestry in the racial disparity in RAAS inhibitor associated reductions in HFrEF hospitalizations. METHODS: The primary outcome was time to first heart failure hospitalization. A (de-identified) heart failure patient registry and data from the GUIDE-IT multi-center randomized control trial were analyzed with Cox proportional hazards models un/adjusted for clinical risk factors, death as a competing risk, and time-varying RAAS inhibitor exposure. The proportion of Yoruba African ancestry was quantified.. Analysis of self - identified race were performed in both the registry and GUIDE-IT. Analysis of genomic ancestry was only performed in the registry since this information was not available in GUIDE-IT. A fixed effect meta-analysis combined results of both the registry and GUIDE-IT for race. RESULTS: The registry had 1010 total HFrEF patients (Black = 509 and White = 501) with 852 having ancestry quantification (>80% Yoruba African Ancestry = 381 and <5% Yoruba African Ancestry = 471). GUIDE-IT had 810 HFrEF patients (Black = 322 and White = 488). There was no significant difference in the association of RAAS inhibitor exposure with heart failure hospitalization by race (meta-analysis p-value for race*RAAS inhibitor exposure interaction = 0.49; Black patients HR [95% CI] for RAAS inhibitor exposure = 0.89 [0.64-1.23)] P = 0.47; White patients = 1.20 (0.83-1.75) P = 0.34). Results were similar when analyzed by ancestry (p-value for ancestry*RAAS inhibitor exposure interaction = 0.57; >80% Yoruba African Ancestry = 0.93 [0.51-1.69] P = 0.80; <5% Yoruba African Ancestry = 1.29 [0.57-2.92] P = 0.54). CONCLUSIONS: In contrast to a previous meta-analysis, this more contemporary analysis of 2 HFrEF patient datasets demonstrates the absence of a racial disparity in RAAS inhibitor associated reductions in heart failure hospitalizations. The difference in this racial disparity over time may be due to improvements in background heart failure therapies, racial differences in healthcare usage, and the use of more advanced statistical approaches.

Differences in provider approach to initiating and titrating guideline directed medical therapy in heart failure with reduced ejection fraction.

BACKGROUND: Despite the strong evidence supporting guideline-directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF), prescription rates in clinical practice are still lacking. METHODS: A survey containing 20 clinical vignettes of patients with HFrEF was answered by a national sample of 127 cardiologists and 68 internal/family medicine physicians. Each vignette had 4-5 options for adjusting GDMT and the option to make no medication changes. Survey respondents could only select one option. For analysis, responses were dichotomized to the answer of interest. RESULTS: Cardiologists were more likely to make GDMT changes than general medicine physicians (91.8% vs. 82.0%; OR 1.84 [1.07-3.19]; p = 0.020). Cardiologists were more likely to initiate beta-blockers (46.3% vs. 32.0%; OR 2.38 [1.18-4.81], p = 0.016), angiotensin receptor blocker/neprilysin inhibitor (ARNI) (63.8% vs. 48.1%; OR 1.76 [1.01-3.09], p = 0.047), and hydralazine and isosorbide dinitrate (HYD/ISDN) (38.2% vs. 23.7%; OR 2.47 [1.48-4.12], p < 0.001) compared to general medicine physicians. No differences were found in initiating angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARBs), initiating mineralocorticoid receptor antagonist (MRA), sodium-glucose transporter protein 2 (SGLT2) inhibitors, digoxin, or ivabradine. CONCLUSIONS: Our results demonstrate cardiologists were more likely to adjust GDMT than general medicine physicians. Future focus on improving GDMT prescribing should target providers other than cardiologists to improve care in patients with HFrEF.

Use of Human-Centered Design Methodology to Develop a Digital Toolkit to Optimize Heart Failure Guideline-Directed Medical Therapy.

BACKGROUND: Guideline-directed medical therapies (GDMTs) improve quality of life and health outcomes for patients with heart failure (HF). However, GDMT utilization is suboptimal among patients with HF. OBJECTIVE: The aims of this study were to engage key stakeholders in semistructured, virtual human-centered design sessions to identify challenges in GDMT optimization posthospitalization and inform the development of a digital toolkit aimed at optimizing HF GDMTs. METHODS: For the human-centered design sessions, we recruited (a) clinicians who care for patients with HF across 3 hospital systems, (b) patients with HF with reduced ejection fraction (ejection fraction ≤ 40%) discharged from the hospital within 30 days of enrollment, and (c) caregivers. All participants were 18 years or older, English speaking, with Internet access. RESULTS: A total of 10 clinicians (median age, 37 years [interquartile range, 35-41], 12 years [interquartile range, 10-14] of experience caring for patients with HF, 80% women, 50% White, 50% nurse practitioners) and three patients and one caregiver (median age 57 years [IQR: 53-60], 75% men, 50% Black, 75% married) were included. Five themes emerged from the clinician sessions on challenges to GDMT optimization (eg, barriers to patient buy-in). Six themes on challenges (eg, managing medications), 4 themes on motivators (eg, regaining independence), and 3 themes on facilitators (eg, social support) to HF management arose from the patient and caregiver sessions. CONCLUSIONS: The clinician, patient, and caregiver insights identified through human-centered design will inform a digital toolkit aimed at optimizing HF GDMTs, including a patient-facing smartphone application and clinician dashboard. This digital toolkit will be evaluated in a multicenter, clinical trial.

Consumer perceptions of the OTC Coach: A clinical decision support system aimed at improving the safe use of over-the-counter medications.

BACKGROUND: There are more than 300,000 over-the-counter (OTC) medications on the market making it challenging for consumers to select safe and effective products to treat their minor ailments. OBJECTIVE: We sought to identify consumer perceptions about the use of a clinical decision support system, OTC Coach, to help them make informed decisions about OTC medications. METHODS: We developed a prototype of the OTC Coach that focused on treating fever in adults. We recruited community members who were 18 years and older via our institutional research website. Participants completed a 30- to 45-minute video interview in which they initially discussed their perceptions and experiences of using OTC medications. We subsequently shared the OTC Coach prototype and sought feedback related to the content and format of the tool. We asked participants to rate their likelihood of using the tool to treat a new symptom (10-point Likert scale, 1 = not at all to 10 = extremely likely) and conducted a qualitative and quantitative analysis of these findings. RESULTS: Among 20 participants, 11 (55%) were female, 10 (50%) were white, and the mean age was 47.9 years (range 18-81 years). Participants reported that the tool was easy to understand. The questions reported as being extremely important by most participants were allergies (n = 17, 85%), increased risk of bleeding (n = 15, 75%), temperature (n = 12, 60%), and duration of symptoms (n = 12, 60%). Three-fourths of participants (n = 15) selected a score of 7 or higher when asked about their likelihood of using this tool for a new symptom. Concerns that were raised included ensuring that the tool accounted for their personal health history, data storage, and accessibility. CONCLUSION: Consumers were interested in using an electronic tool to determine if their symptoms can be self-treated and, if so, which medications are appropriate.

A Community Participatory Approach to Creating Contextually Tailored mHealth Notifications: myBPmyLife Project.

Just-in-time adaptive interventions (JITAIs) are a novel approach to mobile health (mHealth) interventions, sending contextually tailored behavior change notifications to participants when they are more likely to engage, determined by data from wearable devices. We describe a community participatory approach to JITAI notification development for the myBPmyLife Project, a JITAI focused on decreasing sodium consumption and increasing physical activity to reduce blood pressure. Eighty-six participants were interviewed, 50 at a federally qualified health center (FQHC) and 36 at a university clinic. Participants were asked to provide encouraging physical activity and low-sodium diet notifications and provided feedback on researcher-generated notifications to inform revisions. Participant notifications were thematically analyzed using an inductive approach. Participants noted challenging vocabulary, phrasing, and culturally incongruent suggestions in some of the researcher-generated notifications. Community-generated notifications were more direct, used colloquial language, and contained themes of grace. The FQHC participants' notifications expressed more compassion, religiosity, and addressed health-related social needs. University clinic participants' notifications frequently focused on office environments. In summary, our participatory approach to notification development embedded a distinctive community voice within our notifications. Our approach may be generalizable to other communities and serve as a model to create tailored mHealth notifications to their focus population.

Survival Association of Angiotensin Inhibitors in Heart Failure With Reduced Ejection Fraction: Comparisons Using Self-Identified Race and Genomic Ancestry.

BACKGROUND: It remains unclear whether there is a racial disparity in the response to angiotensin inhibitors in patients with heart failure with reduced ejection fraction (HFrEF) and whether the role of genomic ancestry plays a part. Therefore, we compared survival rates associated with angiotensin inhibitors in patients with HFrEF by self-identified race and proportion of West African genomic ancestry. METHODS: Three datasets totaling 1153 and 1480 self-identified Black and White patients, respectively, with HFrEF were meta-analyzed (random effects model) for race-based analyses. One dataset had genomic data for ancestry analyses (416 and 369 self-identified Black and White patients, respectively). Cox proportional hazards regression, adjusted for propensity scores, assessed the association of angiotensin inhibitor exposure with all-cause mortality by self-identified race or proportion of West African genomic ancestry. RESULTS: In meta-analysis of self-identified race, adjusted hazard ratios (95% CI) for exposure to angiotensin inhibitors were similar in self-identified Black and White patients with HFrEF: 0.52 (0.31-0.85) P = 0.006 and 0.54 (0.42-0.71) P = 0.001, respectively. Results were similar when the proportion of West African genomic ancestry was > 80% or < 5%: 0.66 (0.34-1.25) P = 0.200 and 0.56 (0.26-1.23) P = 0.147, respectively. CONCLUSIONS: Among self-identified Black and White patients with HFrEF, reduction in all-cause mortality associated with exposure to angiotensin inhibitors was similar regardless of self-identified race or proportion of West African genomic ancestry.

Predictors of Smartphone and Tablet Use Among Patients With Hypertension: Secondary Analysis of Health Information National Trends Survey Data.

BACKGROUND: Uncontrolled hypertension leads to significant morbidity and mortality. The use of mobile health technology, such as smartphones, for remote blood pressure (BP) monitoring has improved BP control. An increase in BP control is more significant when patients can remotely communicate with their health care providers through technologies and receive feedback. Little is known about the predictors of remote BP monitoring among hypertensive populations. OBJECTIVE: The objective of this study is to quantify the predictors of smartphone and tablet use in achieving health goals and communicating with health care providers via SMS text messaging among hypertensive patients in the United States. METHODS: This study was a cross-sectional, secondary analysis of the 2017 and 2018 Health Information National Trends Survey 5, cycles 1 and 2 data. A total of 3045 respondents answered "Yes" to the question "Has a doctor or other healthcare provider ever told you that you had high blood pressure or hypertension?", which defined the subpopulation used in this study. We applied the Health Information National Trends Survey full sample weight to calculate the population estimates and 50 replicate weights to calculate the SEs of the estimates. We used design-adjusted descriptive statistics to describe the characteristics of respondents who are hypertensive based on relevant survey items. Design-adjusted multivariable logistic regression models were fitted to estimate predictors of achieving health goals with the help of smartphone or tablet and sending or receiving an SMS text message to or from a health care provider in the last 12 months. RESULTS: An estimated 36.9%, SE 0.9% (183,285,150/497,278,883) of the weighted adult population in the United States had hypertension. The mean age of the hypertensive population was 58.3 (SE 0.48) years. Electronic communication with the doctor or doctor's office through email or internet (odds ratio 2.93, 95% CI 1.85-4.63; P<.001) and having a wellness app (odds ratio 1.82, 95% CI 1.16-2.86; P=.02) were significant predictors of using SMS text message communication with a health care professional, adjusting for other demographic and technology-related variables. The odds of achieving health-related goals with the help of a tablet or smartphone declined significantly with older age (P<.001) and ownership of basic cellphones (P=.04). However, they increased significantly with being a woman (P=.045) or with being married (P=.03), having a wellness app (P<.001), using devices other than smartphones or tablets to monitor health (P=.008), making health treatment decisions (P=.048), and discussing with a provider (P=.02) with the help of a tablet or smartphone. CONCLUSIONS: Intervention measures accounting for age, gender, marital status, and the patient's technology-related health behaviors are required to increase smartphone and tablet use in self-care and SMS text message communication with health care providers.

Fewer patients receive recommendations for pharmacotherapy in primary prevention using the 2018 atherosclerotic cardiovascular disease risk estimator.

Shortly after the introduction of the 2013 original Pooled Cohort Equation (PCE), an overestimation of risk was suggested. As such, the updated 2018 PCE was developed to more accurately assess atherosclerotic cardiovascular disease (ASCVD) risk in the population. Hence, this study aims to compare drug prescribing recommendations in a large, real-world patient population, depending on which PCE is used to estimate 10-year ASCVD risk. This retrospective cohort study identified 20,843 patients aged between 40 and 75 years with no previous ASCVD. The 10-year ASCVD risk score was assessed by using both PCE. Patients were assigned to the four risk categories according to the 2018 ACC/AHA guideline. The percentage of patients qualifying for guideline-recommended primary prevention with statins and/or anti-hypertensives were compared between both PCE. Risk reclassification occurred in 26.7% of patients overall (n = 5571), of which 98.1% (n = 5466) were assigned to lower risk categories with the updated PCE. Non-diabetic (14.0%) patients no longer met the threshold for recommending statins as primary prevention with the updated PCE. Likewise, 13.8% of patients with stage I hypertension no longer met the threshold for recommending antihypertensive drugs with the updated PCE. In conclusion, risk reclassification occurred among 26.7% of patients overall, mostly due to lower risk categories assigned by the updated PCE. Up to 14.0% of patients no longer met the threshold for recommending statin therapy and/or antihypertensive drugs by using the updated PCE. These findings suggest that using the updated PCE could translate into fewer patients receiving pharmacotherapy for ASCVD primary prevention.

Disparities in the Use of Guideline-Based Pharmacotherapy Exist for Atherosclerotic Cardiovascular Disease and Heart Failure Patients Who Have Intellectual/Developmental Disabilities in a Commercially Insured Database.

BACKGROUND: Patients who have intellectual/developmental disabilities (IDDs) develop atherosclerotic cardiovascular disease (ASCVD) or heart failure (HF) at rates similar to or higher than the general population. They also face disparities accessing and using health care services. OBJECTIVE: To determine if disparities exist in the use of guideline-based pharmacotherapy (GBP) for ASCVD or HF for adults with IDD. METHODS: Using the 2014 Clinformatics Data Mart Database, adults with ASCVD or HF were divided into IDD or non-IDD groups. Patients with contraindications for GBP medications were excluded. Use of GBP between IDD and non-IDD groups was examined. Subgroup analysis included comparisons between IDD groups. RESULTS: For HF, 1011 patients with IDD and 236,638 non-IDD patients were identified. For ASCVD, 2190 IDD and 790,343 non-IDD patients were identified. We found that 47.9%, 35.8%, and 13.1% of IDD and 58.7%, 48.4%, and 18.9% of non-IDD patients had pharmacy claims for statins (P < 0.001), ß-blockers (P < 0.001), or antiplatelet therapy (P < 0.001), respectively. For HF, 46.8% and 50.3% of IDD and 59.8% and 55.4% of non-IDD patients had pharmacy claims for ß-blockers (P < 0.001) and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs; P = 0.003), respectively. In all but one multivariate regression models patients with IDD were less likely to use GBP than patients in the non-IDD group. Subgroup analysis revealed that patients who had Down syndrome had lower GBP use in 4 of the 5 measures. CONCLUSION AND RELEVANCE: Disparities exist in the use of GBP for patients with IDD with ASCVD or HF. Patients who have an IDD should be examined by clinicians to ensure appropriate access to and use of GBP.

The real world use of combined P-glycoprotein and moderate CYP3A4 inhibitors with rivaroxaban or apixaban increases bleeding.

The use of direct oral anticoagulants for stroke prevention in atrial fibrillation continues to rise. Certain populations may be at higher risk for increased drug exposure and adverse events. Pharmacokinetic studies suggest increased exposure of rivaroxaban and apixaban with combined P-gp and moderate CYP3A4 inhibitors but the clinical relevance of this is unknown. This retrospective cohort study included patients receiving rivaroxaban or apixaban from January 1, 2012 to December 31, 2016 with a moderate inhibitor (amiodarone, dronedarone, diltiazem, verapamil) for at least 3 months in the drug-drug interaction (DDI) group. Propensity matching was used to identify similar control patients without the presence of the DDI. The primary outcome was a time to event analysis of any bleeding episode as defined by the International Society of Thrombosis and Hemostasis. After propensity matching, 213 patients with similar baseline characteristics were included in each group. The mean CHA2DS2-VASc score was 3.0 and median duration of follow-up was 1.45 years. The primary outcome occurred in 26.4% of patients in the DDI group and 18.4% in the control group (hazard ratio 1.8, 95% confidence interval [CI] 1.19 to 2.73; p-value = 0.006). There was no difference in bleeding rates based on type of inhibitor. Use of a combined P-gp and moderate CYP3A4 inhibitor with rivaroxaban or apixaban increased bleeding risk compared to patients without the DDI in this real world, retrospective study. Analysis in a larger patient population is needed to confirm these findings.

Factors that influence patient acceptance of clinical pharmacy services: A nationwide survey.

OBJECTIVE: Examine the factors that influence a patient's likelihood of participating in clinical pharmacy services so that pharmacists can use this knowledge to effectively expand clinical services. METHODS: An online survey was distributed to U.S. citizens 55 years of age or older through a market research company. The survey assessed pharmacy and medication use, general health, interest in clinical pharmacy services, and general demographics. The specific clinical services examined included medication therapy management (MTM) and a collaborative practice agreement (CPA). Logistic regression and best-worst scaling were used to predict the likelihood of participating and determine the motivating factors to participate in clinical pharmacy services, respectively. RESULTS: Two hundred eight (58.45%) respondents reported being likely to participate in MTM services, and 108 (50.6%) reported being likely to participate in the services offered by a pharmacist with a CPA, if offered. The motivations to participate in MTM were driven by pharmacist management of medication interactions and adverse effects (best-worst scores 0.62 and 0.51, respectively). The primary motivator to participate in a CPA was improved physician-pharmacist coordination (best-worst score 0.80). Those with a personal pharmacist were more likely to participate in MTM (odds ratio [OR] 2.43 [95% CI 1.41-4.22], P = 0.002) and a pharmacist CPA (2.08 [1.26-3.44], P = 0.004). Previous experience with MTM increased the likelihood of participating again in MTM (5.98 [95% CI 2.50-14.35], P < 0.001). Patient satisfaction with the pharmacy increased the likelihood of participating in a pharmacist CPA (1.47 [95% CI 1.01-2.13], P = 0.04). CONCLUSION: Patients are interested in clinical pharmacy services for the purposes of medication interaction management, adverse effect management, and improved physician-pharmacist coordination. The factors that influenced the likelihood of participating included having a personal pharmacist, previous experience with MTM, and pharmacy satisfaction. These results suggest a potential impact of the patient-pharmacist relationship on patient participation in clinical services.

A learning pharmacy practice enabled by the pharmacists' patient care process.

To address the Quintuple Aim of health care improvement, the profession of pharmacy is on the verge of a practice transformation that incorporates continuous learning from medication-related data into existing clinical and dispensing roles. The pharmacists' patient care process (PPCP) enables a learning pharmacy practice through the systematic and standardized collection of real-world medication-related data from pharmacists' patient care activities. A learning pharmacy practice continually generates data-powered discoveries as a byproduct of PPCP interactions. In turn, these discoveries improve our medication knowledge while upgrading our predictive powers, thus helping all people achieve optimal health outcomes. Establishing a practice management system connected to the PPCP means that data are generated from every PPCP interaction, combined with existing data, and analyzed by teams of pharmacists and data scientists. The resulting new knowledge is then incorporated into all future PPCP interactions in the form of predictions coupled to actionable advice. The primary purpose of a learning pharmacy practice is to combine the power of predictive modeling with evidence-based best practices to achieve and sustain population-level health improvements. This purpose is achieved by systematically optimizing individual medication use in an equitable manner on a global scale.

Mobile Applications to Improve Medication Adherence.

Background and Introduction: Mobile applications are useful tools to improve medication adherence. As developers continue to improve the features of existing mobile applications, pharmacists should be aware of the current features that are available to patients. There are limited studies available that discuss which applications have the most desirable features. The aim of this study was to compare available mobile applications and identify ideal application features used to improve medication adherence. MATERIALS AND METHODS: As of September 5, 2014, the search terms "medication adherence" and "medication reminder" generated a total of 225 hits. Ideal application features were used to create an Application Score Card to identify applications with the highest number of ideal features. RESULTS: We identified 30 applications that were written in English, medication related, last updated in 2014, and did not meet any exclusion criteria. The top five applications RxNetwork, Mango Health, MyMeds, C3HealthLink, and HuCare are discussed in detail. DISCUSSION: There are numerous studies looking at medication adherence. However, current literature regarding mobile applications to improve medication adherence is lacking. This article will provide pharmacists with a brief overview of the available mobile applications and features that could be used to improve patient adherence to medications. CONCLUSION: Existing mobile applications to improve medication adherence have ideal features that could help patients take medication as prescribed. Once further research is performed to establish their efficacy, pharmacists could begin to recommend mobile applications to their patients.

Impact of a Guideline for the Management of Antimicrobial/Warfarin Interactions in the Inpatient Setting and Across Transition of Care.

BACKGROUND: Drug-drug interactions (DDIs) with warfarin and antimicrobial agents are a common cause of international normalized ratio (INR) instability, which can affect the risk for bleeding and thrombotic events. OBJECTIVE: The purpose of this study was to assess the impact of a comprehensive guideline for the management of warfarin-antimicrobial DDIs across transitions of care. The guideline emphasizes improving identification of significant antimicrobial-warfarin DDIs during hospitalization, empirical warfarin dose modification based on DDI and baseline INR, patient education, documentation of the DDI, communication with outpatient providers regarding the DDI and anticipated antimicrobial stop date, and warfarin dose adjustment on discontinuation of antimicrobial. METHODS: This retrospective, single-center, quasiexperimental, pre-post study compared end points 3 months before and after guideline implementation. The primary outcome was time within therapeutic range (TTR). RESULTS: The study included 78 preguideline and 31 postguideline patients; baseline characteristics were similar between groups. Implementation of the guideline resulted in greater in-hospital TTR (72% vs 50%, P = 0.04) and improved TTR across transition of care (70% vs 46%, P = 0.01). Documentation of DDI in the pharmacy anticoagulation discharge summary significantly improved in the postguideline group (40% vs 14%, P = 0.02) and numerically improved within the daily pharmacy progress notes (94% vs 82%, P = 0.13). The implementation of the guideline was associated with a nonsignificant, numerical reduction in bleeding events compared with the preguideline group (0 vs 4 events, P = 0.11). CONCLUSION: This single-center approach to optimize the comprehensive management of significant antimicrobial-warfarin DDIs resulted in improved communication with outpatient providers and improved INR TTR.

Hyponatremia, Cognitive Function, and Mobility in an Outpatient Heart Failure Population.

BACKGROUND The association of hyponatremia with cognitive impairment and mobility in heart failure (HF) patients is unknown. The purpose of this study was to determine if hyponatremia is associated with cognitive and mobility impairment as measured by simple, validated, and time-sensitive tests. MATERIAL AND METHODS This was a prospective study in patients with reduced and preserved ejection fraction (HFrEF, HFpEF) seen in outpatient HF clinics. Hyponatremia was defined as sodium level ≤136 mEq/L. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA) tool, and mobility was measured with the Timed Up and Go test (TUG-t). RESULTS A total of 121 patients were evaluated; 30% were hyponatremic (134±1.9 mEq/l, range 128-136 mEq/l). Overall, 92% of hyponatremic patients had cognitive impairment (MoCA <26) compared to 76% of the non-hyponatremic patients [relative risk 1.2 (confidence interval: 1.02-1.4, p=0.02)]. In regard to mobility, 72% of hyponatremic patients and 62% of non-hyponatremic patients (p=0.4) had TUG-t times that were considered to be worse than average. A total of 84% (N=76) of HFrEF and 71% (N=22) of HFpEF patients had cognitive impairment (p=0.86). HFrEF patients had significantly lower overall MoCA scores (21.2±3.7 vs. 23.3±3.6, p=0.006) and similar TUG-t times compared to HFpEF patients. CONCLUSIONS Most heart failure patients (HFrEF and HFpEF) seen in an ambulatory setting had impairment of cognitive function and mobility, with a higher prevalence among those with hyponatremia. Screening can be done using tests that can be administered in a clinical setting.

A web application for self-monitoring improves symptoms in chronic systolic heart failure.

OBJECTIVE: The objective of this study was to determine if a Web application that promoted mindfulness of the progress of the chronic disease through self-monitoring improved quality of life in heart failure. MATERIALS AND METHODS: This was a prospective single-center single-group study. Participants were instructed how to use the Web application and to perform self-monitoring daily for 12 weeks. A comprehensive physical exam, assessment of New York Heart Association (NYHA) class, the Minnesota Living with Heart Failure Questionnaire (MLHFQ), and an evaluation of self-management were performed in person at baseline and at 12 weeks. RESULTS: Participants consisted of older (mean, 59 years), predominantly female (63%) adults with NYHA class II or III symptoms. NYHA classification (preintervention versus postintervention, 2.5±0.13 versus 2.0±0.13; p=0.0032) and MLHFQ score (55.7±4.6 versus 42.6±5.1, respectively; p=0.0078) improved over 12 weeks of self-monitoring. A trend toward improvement was also demonstrated in weight (preintervention versus postintervention, 209±9.6 pounds versus 207±9.4 pounds; by paired t test, p=0.389), number of times exercised per week (1.29±0.5 versus 2.5±0.6, respectively; p=0.3), and walk distance (572±147 yards versus 845±187 yards, respectively; p=0.119). Jugular venous distention (preintervention versus postintervention, 8.1±0.6 cm versus 6.7±0.3 cm; p=0.083) and peripheral edema (29.2% versus 16.7%, respectively; p=0.375) decreased after 12 weeks of self-monitoring via the Web application. CONCLUSIONS: A Web application for self-monitoring heart failure over 12 weeks improved both NYHA classification and MLHFQ score. The trend in improved physical activity and physical exam support these outcomes. The number of patients reporting a sodium-restricted diet increased over the 12 weeks, which may have led to the positive findings.

Comparison of practice patterns between inpatient cardiology pharmacists with and without added qualifications in cardiology.

BACKGROUND: There is a paucity of data comparing practice patterns between board-certified specialists with added qualifications in cardiology (AQCV) and cardiovascular pharmacists without these credentials. PURPOSE: The purpose is to characterize differences in practice between inpatient pharmacists with and without AQCV. METHODS: We conducted a multicenter, retrospective, cross-sectional, case-controlled survey. An AQCV pharmacist list was extracted from the Board of Pharmacy Specialties Web site. Hospitals with AQCV pharmacists comprised the case group. Hospitals were excluded if the AQCV pharmacists did not provide direct patient care, practiced in the outpatient setting, or were in a Veterans Affairs hospital. Each case hospital was matched to hospitals without an AQCV pharmacist in a 1:3 ratio (case:control) by region, cardiovascular discharges, and teaching hospital status. Institutions completed a survey characterizing their pharmacy services. RESULTS: Fifty-six hospitals completed the survey (21 AQCV, 35 non-AQCV). More AQCV pharmacists participated on rounds (100% vs 82.9%, P = .04) and devoted more time performing administrative tasks (20.5% ± 15.3% vs 11.1% ± 8.1%, P = .001) than non-AQCV pharmacists. Conversely, AQCV pharmacists spent less time providing clinical care (52.4% ± 14.5% vs 66.2% ± 19.8%, P = .007), were less involved with drug protocol management (71.4% vs 91.4%, P = .05), and performed less order verification than non-AQCV pharmacists. CONCLUSIONS: Practice patterns differ between inpatient pharmacists with and without AQCV. Further research is needed to determine whether AQCV credentialing improves patient outcomes and to delineate what specific tasks performed by inpatient cardiology pharmacists may improve patient outcomes.

Heart failure assessment at the community pharmacy level: a feasibility pilot study.

BACKGROUND: A key element missing in disease-management programs for heart failure (HF) is participation of the community pharmacist. The purpose of this study is to determine if a simple and efficient clinical tool will allow community pharmacists to identify patients at risk for worsening HF. DESIGN: The One Minute Clinic for Heart Failure (TOM-C HF) was developed as a simple six-item symptom screening tool to be used during routine patient/customer interactions. SETTING: Ten community pharmacies located in the upper Midwest. PATIENTS: Self-identified HF patients. RESULTS: 121 unique patients were evaluated over a 12-month period. The application of this clinical tool took between 1 and 5 minutes in over 80% of the interactions. Seventy-five patients (62%) had one or more signs or symptoms of worsening HF. The most common symptoms detected included edema (39%) and increased shortness of breath (17%). Self-reported weight gain of more than 5 pounds was seen in 19% of patients. CONCLUSION: The TOM-C HF tool was used to identify patients in a time-efficient manner in the community pharmacy setting who appear to be developing worsening HF. Inclusion of the community pharmacists as an early screen for HF decompensation may be an important link in disease-management programs to help reduce hospital readmission rates.

Utilization of a computerized clinical surveillance system to increase acute myocardial infarction core measure compliance.

BACKGROUND: Clinical surveillance systems (CSS) are utilized by many health care institutions to help identify at-risk patients, prioritize care, improve the clinical services provided, and increase compliance with the Center for Medicare and Medicaid Services (CMS) core measures. OBJECTIVE: This study will assess the accuracy and practicality of a CMS acute myocardial infarction (AMI) alert, provided by the CSS Theradoc, designed to increase compliance with medications required at discharge in AMI patients. METHODS: This is a single-center, retrospective cohort review to determine the sensitivity and specificity of the Theradoc CMS AMI alert. All patients with a Theradoc CMS AMI alert were analyzed for AMI occurrence and omission of CMS-required discharge medications. Secondary endpoints regarding alert times and quantity were also assessed to address the practicality of implementing the alert. RESULTS: Data were collected on patients with alerts occurring between January 1, 2011, and December 31, 2011 (N = 962). The Theradoc CSS alert was found to have a sensitivity of 100% and specificity of 4.79%, signifying a gross amount of false positives. No modifications to the alert definitions or timing were able to increase the specificity to >10%. CONCLUSIONS: Regardless of the high sensitivity, the Theradoc CMS AMI alert does not have the appropriate level of specificity to utilize at the study institution at this time.

Differences in the Approach to Guideline-Directed Medical Therapy in Patients with Heart Failure with Reduced Ejection Fraction: A Survey of Cardiologists, Internists, and Pharmacists.

Introduction: Guideline-directed medical therapy (GDMT) has significantly improved outcomes in patients with heart failure with reduced ejection fraction (HFrEF). However, GDMT prescribing remains suboptimal. The purpose of this study was to survey cardiologists, internists, and pharmacists on their approach to GDMT prescribing. Methods: A survey containing 20 clinical vignettes of patients with HFrEF was answered by 127 cardiologists, 68 internists, and 89 pharmacists. Each vignette presented options for adjusting GDMT. Responses were dichotomized to the answer of interest. A mixed-effect model was used to calculate the odds of changing GDMT between pharmacists and physicians. Results: Pharmacists were more likely to make changes to GDMT compared with internists (92.1% vs 82%; odds ratio [OR] 3.02 [1.50-6.06]; p=0.002). In medically-naïve patients, pharmacists were more likely to initiate beta-blockers than internists (45.4% vs 32.0%; OR 2.19 [1.00-4.79], p=0.049). Pharmacists were more likely than both internists and cardiologists to initiate mineralocorticoid receptor antagonists (34.4% vs 11.5%; OR 4.95 [2.41-10.18]; p<0.001 and 34.4% vs 13.9%; OR 3.95 [2.16-7.21]; p<0.001). Pharmacists were more likely than both internists and cardiologists to titrate beta-blockers (30.9% vs 16.4%; OR 3.15 [1.92-5.19]; p<0.001 and 30.9% vs 22.0%; OR 1.88 [0.18-2.87]; p=0.0030). Pharmacists were more likely than internists to titrate angiotensin receptor-neprilysin inhibitors (ARNI) (61.8% vs 34.1%; OR 3.54 [1.50-8.39]; p=0.004). Conclusions: The survey results show pharmacists were more likely to make any adjustments to GDMT than internists and cardiologists. Pharmacists prefer adding spironolactone and titrating beta-blockers compared with cardiologists and internists. Compared with only internists, pharmacists were more likely to initiate beta-blockers and titrate the dose of ARNI.