Evaluation of missed opportunities for pharmacotherapy management of heart failure in primary care

Purpose: Titrating heart failure (HF) medications to target doses is a cornerstone of evidence-based HF management. Patients who are followed by a specialty HF disease management program (HFDMP) often have follow-up appointments with their primary care providers (PCP) between HF clinic visits. We aimed to identify whether PCPs are missing opportunities for HF pharmacotherapy optimization at annual appointments.

Methods: Medical records of 209 patients enrolled in the HFDMP at a large VA Medical Center were reviewed. Laboratory data, vital signs, physical exam information and patient-reported symptoms were collected and analyzed to determine whether an opportunity for HF pharmacotherapy optimization existed at the time of the patient’s annual PCP appointment. Patients were included in the study if there was a clear opportunity for medication adjustment based on accepted guidelines and published literature.

Results: We identified 50 PCP visits with clear opportunities for HF pharmacotherapy optimization, encompassing 77 potential interventions. Only 13 (17%) potential interventions were implemented. PCPs intervened to manage uncontrolled hypertension most often, in 6 of 14 (43%) opportunities. PCPs intervened to titrate beta blockers, ACE inhibitors or ARBs, and aldosterone antagonists in 0 of 13 (0%), 2 of 24 (8%), and 1 of 20 (5%) opportunities, respectively.

Conclusion: PCPs are missing opportunities to optimize HF pharmacotherapy for their patients who are enrolled in a HFDMP. HF patients may benefit from more timely HF pharmacotherapy optimization if a teamwork-based approach is established between primary care providers and specialty HF providers. Primary care clinical pharmacists can be utilized to assist PCPs with HF pharmacotherapy adjustment and monitoring.