Effectiveness of the pharmacist-involved multidisciplinary management of heart failure to improve readmission and mortality rates: systematic review and meta-analysis of randomized controlled trials

Background: Heart Failure (HF) is characterized by, high rates of mortality and morbidity, unacceptably high readmission rates, and impaired quality of life. There is emerging evidence that HF patients who receive pharmacist-involved multidisciplinary care have better clinical outcomes. Purpose: To review randomized controlled trials (RCTs) of pharmacist-involved multidisciplinary management of HF to examine the effectiveness on 1) Primary Outcomes: HF hospitalizations, and HF mortality 2) Secondary Outcomes: all-cause hospitalizations and all-cause mortality, composite endpoint (all-cause mortality and all-cause hospitalizations), medication adherence, HF knowledge, self-care and cost effectiveness. Methods: We searched PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, and Cochrane library from inception through March 2017. Bibliographies of relevant studies and systematic reviews were hand-searched. English language peer-reviewed RCTs comparing pharmacist-involved multidisciplinary intervention with usual care were included. This study was conducted in accordance with the Cochrane Collaboration Methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement for Reporting. We registered our protocol with the International Prospective Register of Systematic Reviews (PROSPERO). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to rate the quality of the evidence. Results: Eighteen RCTs (n=4630 patients) were included for systematic review, and 16 (n=4447 patients) for meta-analysis. In this review meta-analysis the pooled estimate showed a significant reduction in HF hospitalizations {odd ratio (OR) 0.72 [95% confidence interval (CI) 0.55–0.93], P=0.01, heterogeneity (I2)=39%} but no reduction in HF mortality [OR, 1.56, 95% CI (0.60–4.03), P=0.36, I2= 0%]. We observed a significant reduction in all-cause hospitalizations [OR 0.76, 95% CI (0.60–0.96), P=0.02, I2= 52%] and all-cause mortality showed a similar, but non-significant trend [OR 0.92, 95% CI (0.74–1.13), P=0.476, I2= 9%]. The effect on medication adherence was heterogeneous, significant improvement (P<0.05) as well as a non-significant improvement. There was also evidence to support significant improvements in HF knowledge (P<0.05), and non-significant improvements in health care costs, self-care, and composite endpoint [OR 0.97, 95% CI (0.82–1.16), P=0.74, I2= 0%]. Conclusions: According to the GRADE evaluation, we rated high quality evidence for the significant reduction of HF hospitalizations, all-cause hospitalizations, and improvement in medication adherence, and HF knowledge. The pharmacist is a vital member of a multidisciplinary team in HF management to improve clinical outcomes.