Publications

BACKGROUND

Mineralocorticoid receptor antagonists (MRA) are an underutilized therapy for heart failure with a reduced ejection fraction (HFrEF), but the current impact of hospitalization on MRA use is not well characterized. The objective of this study was to describe contemporary MRA prescription for heart failure patients before and after the full scope of hospitalizations and the association between MRA discharge prescription and post-hospitalization outcomes.

METHODS

We conducted a retrospective cohort study at an academic hospital system in 2013-2016. Among 1500 included hospitalizations of 1009 unique patients with HFrEF and without MRA contraindication, the mean age was 71.9 ± 13.6 years and 443 (29.5%) were female. We compared MRA prescription before and after hospitalizations with McNemar's test and between patients with principal and secondary diagnoses of HFrEF with the chi-square test, and association of MRA discharge prescription with 30-day and 180-day mortality and readmissions using generalized estimating equations.

RESULTS

MRA prescriptions increased from 303 (20.2%) to 375 (25.0%) at discharge (+4.8%, p < 0.0001). More patients with principal diagnosis of HFrEF compared to those hospitalized for other reasons received MRA (34.9% versus 21.3%, p < 0.0001) and had them initiated (21.8% versus 9.7%, p < 0.0001). MRA prescription at discharge was not associated with mortality or readmission at 30 and 180 days, and there was no interaction with principal/secondary diagnosis.

CONCLUSIONS

Among hospitalized HFrEF patients, 75% did not receive MRA before or after hospitalization, and nearly 90% of eligible patients did not have MRA initiated. As we found no signal for short-term harm after discharge, hospitalization may represent an opportunity to initiate guideline-directed heart failure therapy.

OBJECTIVE

To discuss the design and implementation of a community pharmacy-initiated HIV pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) program developed in collaboration with the San Francisco Department of Public Health (SFDPH).

SETTING

A community pharmacy in San Francisco and the SFDPH developed a collaborative practice agreement (CPA) that allowed community pharmacists to initiate PrEP and PEP to prevent HIV acquisition and increase uptake in vulnerable populations.

PRACTICE DESCRIPTION

A community pharmacy in San Francisco's Mission District, an urban, historically Hispanic/Latino/Latinx neighborhood. The primary collaborative practice team consisted of 1 community pharmacy technician, 4 community pharmacists, and 1 designated overseeing physician at SFDPH.

PRACTICE INNOVATION

The pharmacy and the SFDPH collaborated together for 20 months from start to implementation of the CPA and the PrEP program. An interdisciplinary team of pharmacists, pharmacy personnel, public health physicians, and health department staff members worked together to design, launch, and maintain the program. Pharmacists were trained by SFDPH staff members on HIV testing and counseling and implementation of the PrEP protocol, including PEP initiation and sexually transmitted disease testing. A Department of Public Health secure portal was used to share patient information. An SFDPH physician reviewed patients' charts regularly and communicated with PrEP pharmacists as needed.

RESULTS

Between April 2018 and the end of March 2019, 6 patients received PEP and 53 patients completed a PrEP initiation visit, of whom 96% (n = 51) filled their prescription. Approximately 47% (n = 24) of clients who started PrEP self-identified as Hispanic or Latino, 10% (n = 5) were black or African American, and 82% (n = 42) identified as men who have sex with men.

CONCLUSION

Implementation of a CPA between a community pharmacy and a local health department enabled the launch of pharmacist-delivered PrEP, further expanding the landscape of access points to vulnerable populations in San Francisco.