title: Improvement of guideline β-blocker prescribing in heart failure: a cluster-randomized pragmatic trial of a pharmacy intervention.
abstract: BACKGROUND
  Treatment with specific beta-blockers and doses recommended by guidelines is often not achieved in practice. We evaluated an intervention directed to the pharmacy to improve prescribing.
  
  
  RESULTS
  We conducted a pragmatic cluster-randomized trial, where facilities (n = 12) with patients (n = 220) were the clusters. Eligible patients had a beta-blocker prescription that was not guideline concordant. Level 1 intervention included information to a pharmacist on facility guideline concordance. Level 2 also provided a list of patients not meeting guideline goals. Intervention and follow-up periods were each 6 months. Achievement of full concordance with recommendations was low (4%-5%) in both groups, primarily due to lack of tolerability. However, compared with level 1, the level 2 intervention was associated with 1.9-fold greater odds of improvement in prescribing (95% confidence interval [CI] 1.1-3.2). Level 2 patients also had greater odds of a higher dose (1.9, 95% CI 1.1-3.3). The intervention was aided by the patient lists provided, the electronic medical record system, and staff support.
  
  
  CONCLUSIONS
  In actual practice, full achievement of guideline goals was low. However, a simple intervention targeting pharmacy moved patients toward guideline goals. As health care systems incorporate electronic medical records, this intervention should have broader feasibility.
authors.affiliation: Department of Veterans Affairs, Pharmacy Benefits Management Services, Hines, Illinois 60141, USA. madeline.mccarren@va.gov
authors.forename: Madeline
authors.initials: M
authors.lastname: McCarren
authors.forename: Elaine
authors.initials: E
authors.lastname: Furmaga
authors.forename: Cynthia A
authors.initials: CA
authors.lastname: Jackevicius
authors.forename: Anju
authors.initials: A
authors.lastname: Sahay
authors.forename: Tami L
authors.initials: TL
authors.lastname: Coppler
authors.forename: Jennifer
authors.initials: J
authors.lastname: Katzianer
authors.forename: Randi Lynn
authors.initials: RL
authors.lastname: Griffiths
authors.forename: Ivy
authors.initials: I
authors.lastname: Tonnu-Mihara
authors.forename: Paul
authors.initials: P
authors.lastname: Heidenreich
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D000369:Aged, 80 and over; D016000:Cluster Analysis; D057286:Electronic Health Records / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010604:Pharmacy / Q000592:standards*; D017410:Practice Guidelines as Topic / Q000592:standards*
chemical_list: D000319:Adrenergic beta-Antagonists
keywords: Target dose; health information technology; pharmacy intervention; pragmatic trial; quality improvement