Enlisting pharmacists and nurse practitioners to manage medications for patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF) confers health benefits and is cost-effective, according to a simulation model study.

“This study found that additional pharmacist- and nurse-practitioner-led medication management in this context can not only save lives and reduce hospitalizations but it can also do so in a way that provides strong value for money,” first author Blair J. MacDonald, PharmD, a PhD candidate at the University of British Columbia in Vancouver, told Medscape News Canada.

The results support the expansion of this care to improve the uptake of guideline-directed medication therapy (GDMT) and patient outcomes, according to the authors.

The findings were published on June 28 in the Canadian Journal of Cardiology.

Reduced Deaths and Hospitalizations

“We know that patients with HFrEF can get substantial benefits from GDMT, but unfortunately, we also know that the use of these effective medications remains suboptimal. Part of the reason is that many patients in Canada lack access to specialized medication management services. We conducted this study to better understand the impacts of additional pharmacist- and nurse-practitioner-led medication management services to address this evidence gap,” said MacDonald.

Using an economic model developed from information gleaned from multiple datasets, the investigators simulated two scenarios for patients recently diagnosed with HFrEF. In the first scenario, the patients received usual care. In the second, they received usual care plus additional pharmacist- and nurse-practitioner-led medication management.

“Usual care is what most patients with heart failure in British Columbia currently receive, usually from their family physician,” said MacDonald. The researchers then modeled what would happen to these patients over 1 year.

The model showed that pharmacist- and nurse-practitioner-led medication management would reduce deaths (from 7.2 to 6.2 per 100 patients) and heart failure hospitalizations (from 10.8 to 8.4 per 100 patients) and would increase quality-adjusted life-years (QALYs) by 1.76. The cost for implementing such a program was estimated at $7437 per QALY.

“This additional cost to the healthcare system is well within the threshold of $50,000: the amount the healthcare system is willing to pay to get 1 QALY,” noted MacDonald. “Now that we have made the case in favor of expanding care for heart failure, it’s up to the different health systems to figure out exactly how best to implement this in their local context,” he added.

Addressing a Care Gap

“It’s a great study,” Heather Kertland, PharmD, assistant professor of pharmacy at the University of Toronto, told Medscape News Canada. “It builds into evidence for clinicians and administrators to hopefully address a care gap.”

Many patients with HFrEF are not receiving medications that could prolong their lives, and pharmacists and nurse practitioners are effective in addressing this care gap, said Kertland. “This research is telling us that, although it’s an additional cost, it is reasonable and much within what the willingness-to-pay standard has been.”

Monica Parry, RN, PhD, professor in the Lawrence Bloomberg Faculty of Nursing at the University of Toronto and a nurse practitioner at the Kingston Health Sciences Centre’s cardiac program in Ontario, has led medication management efforts at her center for several years. She described her recent experiences to Medscape News Canada.

“I was asked to assist in the heart failure clinic this spring because of the large number of patients and the low resources available to follow and titrate GDMT. There are now five of us in the clinic (four are full-time, and I am casual) delivering virtual and in-person care. I can attest to the improved outcomes,” said Parry.

“The fact is that we intake many more patients than we discharge in a week. We are increasing the number of in-person heart failure clinics so that we can schedule any patient we are worried about for an in-person focused physical examination,” she continued. The outpatient process works well at nurse-practitioner-only clinics and nurse-practitioner-and-cardiologist clinics, said Parry. “It’s a real partnership with patients and their families. Patients track their weights, blood pressures, and heart rates and report them to us during our virtual visits. The nurse practitioners titrate medications and order labs to monitor renal function. It is a true demonstration of shared decision-making. We also work with our local community paramedics who will provide in-home wellness checks to patients. The Ontario Health at Home program offers remote monitoring for patients, as well. We very much work as a team to improve outcomes for patients.”

The work was supported by Cardiac Services BC, Michael Smith Health Research BC, and the Canadian Institutes of Health Research. Macdonald, Kertland, and Parry reported having no relevant financial relationships.