October 2015, Vol 3, No 10 - Inside Cardiometabolic Health
Michael Botros, PharmD
Nicole East, PharmD

Heart failure (HF) is a chronic and disabling condition that is considered the most common cause of hospital admissions in adults aged >65 years in the United States.1 It is responsible for >1 million hospitalizations every year.1

Thirty-day readmission is a performance outcome measure used by Medicare, and is defined as unplanned readmission to any acute care hospital, for any cause, within 30 days of discharge from a hospitalization.2 It has been incorporated as part of hospital reimbursement adjustment under the Hospital Readmissions Reduction Program.3

Taking into account Medicare’s 30-day readmission measure and the high rate of readmissions associated with HF, it is incumbent on pharmacists and other healthcare providers in the community to understand the factors associated with high readmission rates and the impact of outpatient HF management on reducing 30-day readmission. In a recent study, Sehgal and colleagues evaluated the association between inappropriate use of medications and hospital readmission among elderly patients who were readmitted to a hospital within 30 days of discharge, regardless of the diagnosis at the time of admission.4 They found that the most common factor associated with readmission was congestive HF; polypharmacy and inappropriate use of medications were also associated with readmission.

These data suggest that there is a role for pharmacists and healthcare providers in the community to target geriatric patients with HF by identifying preventable medication errors and providing adequate patient counseling to avoid readmissions. Pharmacists are also in a unique position to communicate medication issues with patients’ primary care physicians, and educate patients on disease state management.

The Downstream Effects of Polypharmacy

More often than not, elderly patients are faced with comorbidities and have to juggle multiple medications. Elderly patients with congestive HF have a high prevalence of noncardiac comorbidities, including hypertension, chronic obstructive pulmonary disease, and diabetes mellitus.5 These conditions require multiple medications, and increase the risk for deleterious effects associated with polypharmacy.

Polypharmacy, which is defined as taking ≥5 medications simultaneously, has been shown to lead to poor medication adherence, higher risk for drug interactions, and adverse events.6 Polypharmacy is also associated with more complicated drug regimens, which can be harder for patients to follow, especially in elderly populations. Furthermore, geriatric patients experience a natural linear decline in creatinine clearance that can add a level of complexity to therapy management; this decline can be expedited in patients with comorbidities, including hypertension and diabetes.4

What is typically seen in cases of polypharmacy is that the addition of more medications to patients’ regimens, along with insufficient communication, leads to poor adherence to medication. Nonadherence can lead to worsening of symptoms, followed by a greater rate of hospital readmission.7 In one study, investigators evaluated medication adherence in elderly patients dealing with polypharmacy and found that patients discontinued medications on their own because they believed it was unnecessary.8 Patients also independently changed medication dosages because they were afraid of adverse events.

Patients with HF are more likely to be nonadherent to their medication, and, according to research, have a shorter time to readmission.7 Knafl and Riegel evaluated poor adherence in patients with HF and found that new diagnosis, older age with comorbid conditions, polypharmacy, and poor sleep increased the risk for poor compliance.9

Community pharmacists and healthcare providers can provide patient counseling services and follow-up visits individualized to patients’ needs, a level of understanding to counter the effects of polypharmacy, and improve medication adherence.

Impact of Medication Adherence

In addition to polypharmacy, other challenges exist that impact patient adherence to their medication. In one study describing adherence to prescription drugs in a cohort of elderly patients taking multiple medications, the investigators found that a high percentage of patients did not understand the purpose of their medications.8,10 In addition, the investigators concluded that the increasing number of dispensed medications at discharge was correlated with nonadherence.8 During counseling sessions, community pharmacists and healthcare providers should take some time to educate patients about the medications they are taking and why they are taking them, especially populations with special considerations, such as geriatric patients.

Furthermore, newly diagnosed pa­tients with HF have to deal with what they may consider inconveniences that were absent before they were diagnosed with the condition. Depending on the patient, these may include making lifestyle modifications, such as fluid and salt restrictions, as well as taking greater responsibilities with their health, including monitoring their weight and smoking cessation.11 In another study of patients with HF discharged from rural hospitals, the investigators found that nonadherence to self-management of the condition was the most common cause of HF-related readmission, accounting for 50% of readmissions.12 It is important to stress to patients that self-management goes beyond taking their medication, and also includes adherence to lifestyle modifications and taking responsibility for their health.

Pharmacist-led interventions can have an impact on medication adherence in patients with HF. Bouvy and colleagues conducted a randomized controlled study evaluating medication adherence in patients with HF, predominantly New York Heart Association classes II and III, treated with loop diuretics.13 The intervention group received monthly, pharmacist-led consultations, and the control group received usual care. At the end of the 6-month study period, the investigators found that patients in the intervention group had 140/7656 days without the use of loop diuretics, compared with 337/6196 days in the control arm (relative risk, 0.33; 95% confidence interval, 0.24-0.38).

Nonadherence to medications could be a result of a variety of factors ranging from social and economic, to personality traits, beliefs, and medical comorbidities. By spending time discussing self-management and medication-specific factors such as medication names, doses, indications, and mode of administration, pharmacists have the opportunity to play a significant role in improving medication adherence and decreasing hospital readmission.

Making an Impact in the Community

Numerous studies have evaluated the role of community pharmacists in patients with HF. In one study, the investigators explored the views of pharmacists and patients who were part of a regimented, community pharmacy-based HF service.14 Community pharmacists received formalized training and provided a consultation service that included evaluating patients’ understanding of the medications they were taking, and addressing questions as well as any adherence issues they may have. Patients and pharmacists interviewed as part of the study reported that the HF service filled a current gap in care.

In particular, patients reported that the service had a positive impact on their treatment. Accessibility, approachability, and support were other benefits patients reported in the study. Patients were also able to use their pharmacist’s suggestions, which were made based on the presenting symptoms, when deciding whether to see their primary care physician. Patients also reported feeling better about taking their medications, developing a better understanding of medication adherence, and following up with the pharmacist.

Pharmacists delivering the care reported that they were more confident consulting with patients about HF. The study authors also observed that a strong collaboration with primary care providers played a role in pharmacists’ confidence. In addition, the study authors noted that pharmacists had difficulty getting patients to talk about comorbidities other than HF, and persuading patients to modify their behavior. Pharmacists also reported more pressure for time because of unpredictable fluctuations in their workloads.

Another study performed in the community setting included a home health teaching service on medication adherence provided by pharmacists.15 This method involved 1 in-home visit by a postgraduate year 1 community pharmacist resident who provided complete medication reconciliation and counseling to the patient, followed by 2 follow-up phone calls within a 4-week time frame. Though this study was small, it proved helpful in streamlining transitions of care from an inpatient to outpatient setting, enhancing medication adherence, and reducing 30-day hospital readmission rates.

Through interventions such as counseling and educational services, community pharmacists and healthcare providers can have an impactful role in elderly patients with HF, including raising awareness about polypharmacy, improving medication adherence, and ultimately reducing 30-day readmissions in this patient population.

Discussion

Hospital readmissions are a significant issue in healthcare that needs to be addressed. It represents a gap in patient care indicative of a poor transition to outpatient care. Community pharmacists and healthcare providers can help fill this gap through counseling, minimizing the risks associated with polypharmacy, and appropriately referring patients to their physicians when they start to decompensate.

Pharmacists can promote adherence by educating patients on self-management, use of drugs, and importance of compliance. In addition, studies have shown that following up with patients and providing consultations on several occasions can help form a relationship between community pharmacists and patients, and meet patients’ needs by providing personalized recommendations.14,15

Community pharmacists can also provide cognitive-based counseling services that can increase patients’ self-management capabilities. Pharmacy services have been reported to increase patients’ understanding of HF and raise patient awareness about the purpose of their therapy. Through medication teaching services and follow-up support, community pharmacists and healthcare providers can play a significant role in medication adherence and reduction in 30-day hospital readmissions.

During counseling sessions, community pharmacists may help assess the patient’s understanding of HF and the purpose of therapy by asking open-ended questions. Through active listening, they can identify and address barriers to adherence, and emphasize the importance of medication adherence and lifestyle modifications. Pharmacists can also use this opportunity to offer a courtesy follow-up phone call. A follow-up phone call service may help evaluate patients’ progress and tolerance for medications, and let them know the pharmacists are available to address any questions or concerns that may arise.14,15 In addition, following up and checking in with patients regularly allows pharmacists to better assess whether patients need to be referred to their physician for therapy adjustments. By identifying these patients needing referrals, pharmacists can proactively help prevent unnecessary emergency department visits.

Community pharmacists are in a prime position in the healthcare system to detect and resolve drug-related problems associated with polypharmacy, thereby increasing the effectiveness of drug therapy and avoiding adverse events. Nonadherence is a problem that may be reduced or even prevented through proper education. Community pharmacists can play a vital role in enhancing self-management of patients with HF to increase medication adherence, which, in turn, can help reduce hospital readmissions.




References

  1. Desai AS, Stevenson LW. Rehospitalization for heart failure: predict or prevent? Circulation. 2012;126:501-506.
  2. Medicare.gov. 30-day unplanned readmission and death measures. www.medicare.gov/hospitalcompare/Data/30-day-measures.html. Accessed September 2, 2015.
  3. Medicare.gov. Hospital Readmission Reductions Program. www.medicare.gov/hospitalcompare/readmission-reduction-program.html. Accessed September 29, 2015.
  4. Sehgal V, Bajwa SJ, Sehgal R, et al. Polypharmacy and potentially inappropriate medication use as the precipitating factor in readmissions to the hospital. J Family Med Prim Care. 2013;2:194-199.
  5. Braunstein JB, Anderson GF, Gerstenblith G, et al. Noncardiac comorbidity increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure. J Am Coll Cardiol. 2003;42:1226-1233.
  6. Mastromarino V, Casenghi M, Testa M, et al. Polypharmacy in heart failure patients. Curr Heart Fail Rep. 2014;11:212-219.
  7. Lee D, Mansi I, Bhushan S, Parish R. Non-adherence in at-risk heart failure patients: characteristics and outcomes. J Nat Sci. 2015;1:e95.
  8. Pasina L, Brucato AL, Falcone C, et al. Medication non-adherence among elderly patients newly discharged and receiving polypharmacy. Drugs Aging. 2014;31:283-289.
  9. Knafl GJ, Riegel B. What puts heart failure patients at risk for poor medication adherence? Patient Prefer Adherence. 2014;17:1007-1018.
  10. Dunlay SM, Eveleth JM, Shah ND, et al. Medication adherence among community-dwelling patients with heart failure. Mayo Clin Proc. 2011;86:273-281.
  11. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128:1810-1852.
  12. Do V, Young L, Barnason S, Tran H. Relationships between activation level, knowledge, self-efficacy, and self-management behavior in heart failure patients discharged from rural hospitals. F1000Res. 2015;4:150.
  13. Bouvy ML, Heerdink ER, Urquhart J, et al. Effect of a pharmacist-led intervention on diuretic compliance in heart failure patients: a randomized controlled study. J Card Fail. 2003;9:404-411.
  14. Lowrie R, Johansson L, Forsyth P, et al. Experiences of a community pharmacy service to support adherence and self-management in chronic heart failure. Int J Clin Pharm. 2014;36:154-162.
  15. Kalista T, Lemay V, Cohen L. Postdischarge community pharmacist-provided home services for patients after hospitalization for heart failure. J Am Pharm Assoc (2003). 2015;55:438-442.
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