Guideline-led prescribing to heart failure patients in Ireland and Egypt
El Hadidi, Seif
University College Cork
Introduction: Guidelines strongly recommend patients with Heart Failure (HF) be treated with multiple medications proven to improve clinical outcomes, as tolerated. Guideline-led prescribing of HF evidence-based medicines is strongly associated with improved survival, prognosis, and quality of life in HF. The guidelines strongly recommend, and the optimal patient outcomes are achieved with an appropriate prescription of target doses of all HF therapies. The degree to which gaps in medication use and dosing persist in contemporary Irish or Egyptian practices is unclear. Aim: To assess guideline-led prescribing of the evidence-based HF medications in routine clinical practice in Ireland and Egypt and to assess the prevalence of HF-specific potentially inappropriate prescribing in the same Irish and Egyptian clinical settings. Method: Firstly, a narrative literature review was undertaken to determine and compare the available data and gaps in knowledge regarding HF management in Ireland as a developed European country, and Egypt as a developing Middle-Eastern country, with a particular focus on the guideline-directed medical therapies. Secondly, a systematic review was undertaken to identify the objective quantitative tools to assess the quality of HF prescribing practice. Next, a prospective cohort study was conducted on an Irish outpatient population to evaluate the extent of use and dosing of the guideline-directed medical therapies. Then, a multicentre retrospective study was carried out in 14 Long-Term Care (LTC) facilities in Cork County to assess the prevalence of appropriate and potentially inappropriate prescribing practices. In Egypt, a longitudinal observational study was conducted in order to evaluate the prescribing quality and patterns in HF patients in an Egyptian critical care setting at discharge. Finally, a descriptive survey was developed to address the barriers to guideline-led prescribing in a middle-income setting. Results: The literature review identified many gaps in knowledge in the Egyptian and Irish literature on HF. For instance, the studies included in the review did not discuss the target dose prescribing. The systematic review identified the widespread use of the Guideline Adherence Index (GAI-3) in 13 studies worldwide in the quantitative assessment of HF prescribing. The Irish HF outpatient study showed room for optimising the prescription of the guideline-directed medical therapies in 34% of ambulatory patients. No patient achieved the 100% target dose of all three evidence-based medications. The prevalence of potentially inappropriate prescribing was 20%. The Irish LTC study showed that patients with HF were older than those without HF (84.8 ± 7.4 vs 83.4 ± 7.9 years, p-value = 0.024). Loop diuretic was the most frequently prescribed HF medication up to 88% of the total population and renin-angiotensin system inhibitors to 24.2% only. The prevalence of potentially inappropriate prescribing in LTC was 24%. On the other hand, the Egyptian longitudinal study showed the moderate adherence level at discharge from the critical care unit but the potential role of clinical pharmacy service in HF drug therapy optimisation via improving beta-blocker prescription rates by from 24% to 38% and reducing digoxin rates from 34% to 23%. However, the service did not improve the overall guideline adherence levels or the prevalence of inappropriate prescribing. The survey explored some new aspects in HF practice, such as the urgent need for locally-drafted guidelines and the more significant implementation of clinical pharmacy service to optimise the implementation of guideline-led prescribing in routine clinical practice. Conclusion: This thesis has made a significant contribution to the knowledge and generated a much needed conceptual understanding of the complexity of HF guideline-led prescribing. This work reflects the moderate adherence levels to guidelines and high prevalence of potentially inappropriate prescribing in the two countries. None of the prescribers either in Ireland or Egypt prescribed at least a renin-angiotensin system inhibitor to all HF patients despite the strong, long-standing evidence.
Heart failure patients , Prescribing , Ireland , Egypt
El Hadidi, S. Y. S. 2019. Guideline-led prescribing to heart failure patients in Ireland and Egypt. PhD Thesis, University College Cork.