Culturally adapted, pharmacist-supported heart failure day hospital: mixed-methods evaluation of outcomes and implementation mechanisms.

Abstract

Reducing hospitalisations in heart failure (HF) requires organisational models for rapid optimisation, education and structured follow-up. Evidence on complex programmes in outermost or underserved regions and on the mechanisms through which they achieve their effects remains limited. We conducted a convergent mixed-methods evaluation of an anonymised, culturally adapted, pharmacist-supported HF day-hospital programme implemented across two sites in an insular remote European region. The quantitative component was a self-controlled before-after study including all adults attending at least one visit between 1 January 2017 and 31 December 2021 (n=424). The primary outcome was 12-month HF rehospitalisation after versus before enrolment. Secondary outcomes were HF-related bed-days, extended 24-month utilisation, overall survival and optimisation of guideline-directed medical therapy, including quadruple therapy. The qualitative component comprised semi-structured interviews with 10 stakeholders, analysed thematically and integrated with quantitative findings. Using a person-time approach with post-index follow-up censored at death and capped at 12 months, HF rehospitalisation incidence rates decreased from 0.427 (95% CI 0.367 to 0.494) to 0.164 (95% CI 0.127 to 0.207) events per patient-year (incidence rate ratio (IRR) 0.38, 95% CI 0.30 to 0.48). HF bed-days rates decreased from 4.96 (95% CI 4.75 to 5.18) to 1.77 (95% CI 1.64 to 1.90) bed-days per patient-year (IRR 0.43, 95% CI 0.28 to 0.64). Overall survival was 96.0% at 12 months and 91.5% at 24 months. The programme achieved substantial optimisation of core HF therapies and uptake of quadruple therapy. Qualitative findings highlighted enabling mechanisms-multidisciplinary coordination, dedicated infrastructure, pharmacist-supported and nurse-supported titration, bilingual education and engaged leadership-and vulnerabilities including workforce constraints, telemonitoring instability and variable hospital-community integration. In this high-risk, remote setting, this pharmacist-supported, culturally adapted HF day-hospital model was associated with major reductions in HF rehospitalisations and strong implementation of contemporary therapy, supporting integrated, context-sensitive organisational models to improve HF care quality and equity.