Development and implementation of a pharmacist managed clinic for the titration of medications in chronic heart failure patients

Purpose: Published guidelines for the management of chronic heart failure (HF) recommend administration of ACE inhibitors and beta blockers (BB) to patients with an EF<40%.   In addition, Heart Failure Society of America recommends ACE inhibitors be titrated to doses used in clinical trials and BB be initiated at low doses and up-titrated at 2-week intervals.  We previously reported that patients managed in a multi-disciplinary HF clinic are more likely than those managed in a general cardiology (GC) setting to receive guideline recommend therapies.   Therefore we proposed that pharmacist/s specialized in HF management could be a valuable resource to GC for medication titration.

Methods: A specialized clinic was developed for the HF pharmacist to take referrals from GC for systolic HF patients with the purpose of up-titrating ACE inhibitors and BB per guidelines.  The clinic is offered ½ day weekly.   Appointments are scheduled at 30 minute intervals.  At each visit, the pharmacist reviews vitals, symptoms, educational needs, laboratory results and medication regimens.  ACE inhibitor and BB are initiated and/or increased as tolerated.  Prescriptions and the progress note are sent to the referring cardiologist for co-signature.  Patients are seen at 2 week intervals with a cardiologist available for additional consultation as needed.  Pharmacist services are billed via a hospital-based facility fee model at a level 3 or 4 technical fee, depending on visit complexity.

Results: Since clinic implementation (July, 2011), 46 patients have been referred and 126 visits provided by the HF pharmacist.  Clinic acceptance was high with 7 of the 11 GC referring patients for pharmacist management.  Within 1 month of clinic initiation, pharmacist availability needed to be increased from ½ day bi-weekly to weekly.

Conclusion: A pharmacist managed medication titration clinic is a mechanism to assist GC in their treatment of systolic heart failure patients with the ultimate goal of improving patient outcomes.