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Impact of a clinical pharmacy service on heart failure guideline-led prescribing at discharge in an Egyptian critical care unit

Session Poster Session 4

Speaker Margaret Bermingham

Event : Heart Failure 2019

  • Topic : heart failure
  • Sub-topic : Chronic Heart Failure: Multidisciplinary Interventions
  • Session type : Poster Session

Authors : S El Hadidi (Cork,IE), N Bazan (Cairo,EG), E Darwesh (Cairo,EG), S Byrne (Cork,IE), M Bermingham (Cork,IE)

S El Hadidi1 , N Bazan2 , E Darwesh3 , S Byrne1 , M Bermingham1 , 1University College Cork, School of Pharmacy - Cork - Ireland , 2Cairo University, Clinical Pharmacy Department, Critical Care Medicine Department - Cairo - Egypt , 3Future University in Egypt , Faculty of Pharmaceutical Sciences and Pharmaceutical Industries - Cairo - Egypt ,


Introduction: Guideline-led prescribing improves outcomes in heart failure (HF) patients, however, discharge prescriptions may not adhere to the recommendations of the HF guidelines. The clinical pharmacist is uniquely positioned to address guideline-led prescribing in order to optimise HF care and improve patient outcomes.

Purpose: To assess the impact of the introduction of a clinical pharmacy service on guideline-led prescribing to HF patients at discharge from a Critical Care Unit (CCU) in Egypt.

Methods: This was a retrospective observational study of HF patients discharged from CCU from 1st January 2013 to 31st December 2017. The European Society of Cardiology Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 were the reference guidelines. Prescribing was assessed using Guideline Adherence Index (GAI-3), that considers prescribing of renin-angiotensin system inhibitors (RASI); beta-blockers (BB) and mineralocorticoid receptor antagonists (MRA). The adjusted GAI-3 considered patient contraindications to these medicines. The GAI-3 target dose considered the prescription of 50% or more of the recommended target dose of each medicine. High-GAI based management was defined as prescription of =2 disease-modifying therapies. A clinical pharmacy service was introduced to the CCU in January 2016. Multivariable logistic regression analysis was performed to identify associates of High-GAI prescribing.

Results: The study identified 284 HF patients, mean age 66.7±11.5 years and 53.2% male, who were discharged from CCU during the study period.  Loop diuretic was the most frequently prescribed HF medication (85.2%). Prescription rates for GAI-3 agents were RASI 51.4%; BB 29.9%; and MRA 54.9%. Population GAI-3 was 45.5%, however, when adjusted to patients’ contraindications, this increased to 51.0%. GAI-3 target dose was 24.3%. High GAI-3 was prescribed to 136 patients (47.9%). Compared to those with Low GAI-3, these patients were younger (62.6 vs. 70.5 years); less affected by kidney disease (22.1% vs. 33.8%); and had fewer comorbidities (4.9 vs. 5.6), (all p<0.05). Post-introduction of the clinical pharmacy service, BB prescription increased from 24.1% to 38.6% (p<0.001) while digoxin prescription decreased (34.7% vs. 23.7%, p=0.049). Associates of High-GAI were age (Odds Ratio, OR=0.96, 95% Confidence Interval, CI 0.92-0.98), serum creatinine >2.5 mg/dl (OR=0.31, 95% CI 0.09-0.98) and reduced ejection fraction (OR=5.50, 95% CI 2.66-11.55).

Conclusion: This study is the first to consider HF guideline-led prescribing and the role of clinical pharmacy in an Egyptian setting. It highlights inconsistencies between guideline recommendations and current practice. Clinical pharmacy services in Egypt are in their infancy and their impact may increase with time.

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