2026 Southeastern Residency Conference

TITLE: Evaluation of Discharge Medication Prescribing for Patients with Heart Failure Before and After Pharmacist Involvement 
AUTHORS: Uyen Nguyen, Amanda Herndon, and Christine Wong
BACKGROUND: Heart failure (HF) is a leading cause of hospital admissions and readmissions in the United States. The 2022 ACC/AHA/HFSA guidelines recommend that eligible patients with heart failure be discharged on compare guideline-directed medical therapy (GDMT) to reduce morbidity, mortality, and rehospitalization. Despite strong evidence supporting GDMT, many patients are not discharged on all recommended therapies due to system-level gaps, and unaddressed patient-specific barriers. Meta-analysis and observational studies have shown that patients who have medications reviewed by pharmacists prior to discharge are more likely to be discharged on appropriate GDMT. This study aims to assess the effect of pharmacist involvement on adherence to heart failure GDMT prescribing at discharge in a community teaching hospital.

METHODOLOGY: This single-center, comparative study received Institutional Review Board exemption. Retrospective chart review was conducted to compare GDMT prescribing at discharge for all patients with HF before and after pharmacist involvement. During the intervention period, pharmacists received education on assessing HF GDMT eligibility, identifying opportunities for initiation, and ensuring appropriate documentation of contraindications. Providers also received education on potential GDMT initiation, appropriate documentation, medication contraindications, and cost considerations.
Pharmacists reviewed medications and provided recommendations to optimize GDMT for all HF patients prior to discharge. All pharmacist interventions and documentation of contraindications were recorded. Patients who were at least 18 years of age and had a diagnosis of HF were included in the results. Patients who expired or enrolled in hospice or comfort care at any time during the study were excluded. Enrollment of 80 patients in both pre-intervention and post-intervention groups would provide 80% power to detect a 20% difference in the composite GDMT prescribing, with a significant p-value of 0.05.
The primary outcome was the percentage of patients with HF discharged on appropriate composite GDMT. Composite GDMT was defined as adherence to angiotensin-converting-enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor (ACEi/ARB/ARNi), mineralocorticoid receptor antagonists (MRA), and evidence-based beta-blockers (BB) for patients with heart failure with reduced ejection fraction (HFrEF) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) for all patients with heart failure. Secondary outcomes included the percentage of patients prescribed each individual component of GDMT at discharge, including ACEi/ARB/ARNi, BB, MRA, and SGLT2i, when indicated. Adherence was defined as recommended therapy prescribed at discharge or documented contraindications to any component of GDMT.

RESULTS: The primary outcome of composite GDMT before and after pharmacist involvement increased from 40% in the pre-intervention group to 77.5% in the post-intervention group, n= 80 in each group, p-value <0.001. Secondary outcomes showed an increase in each individual component of GDMT. Among patients with HFrEF, n = 31 in each group, prescribing rates in the post-intervention group compared to the pre-intervention group group increased as follow: ACEi/ARB ARNi from 35% to 74%, p 0.002, BB increased from 74% to 100%, p=0.003, MRA increased from 47.5% to 87%, p=0.002. Prescribing of SGLT2i for all HF patients increased from 47.5% to 78%, p<0.001.

CONCLUSIONS: Baseline findings showed significant gaps in the prescribing of GDMT or appropriate documentation of contraindications for patients with heart failure at hospital discharge, particularly with ACEi/ARB/ARNi, MRA, and SGLT2i. Improvements following pharmacist involvement suggest that targeted education, medication review, and real-time recommendations at discharge can increase adherence to evidence-based therapies. The findings highlight the benefit of pharmacist involvement to optimize GDMT, address barriers to prescribing, and improve documentation of contraindications.