International Journal of Clinical Pharmacy

, Volume 36, Issue 1, pp 154–162 | Cite as

Experiences of a community pharmacy service to support adherence and self-management in chronic heart failure

  • Richard LowrieEmail author
  • Lina Johansson
  • Paul Forsyth
  • Stuart Lochhead Bryce
  • Susan McKellar
  • Niamh Fitzgerald
Research Article


Background Heart failure (HF) is common, disabling and deadly. Patients with HF often have poor self-care and medicines non-adherence, which contributes to poor outcomes. Community pharmacy based cognitive services have the potential to help, but we do not know how patients view community-pharmacist-led services for patients with HF. Objective We aimed to explore and portray in detail, the perspectives of patients receiving, and pharmacists delivering an enhanced, pay for performance community pharmacy HF service. Setting Community pharmacies and community-based patients in Greater Glasgow and Clyde, Scotland. Methods Focus groups with pharmacists and semi-structured interviews with individual patients by telephone. Cross sectional thematic analysis of qualitative data used Normalization Process Theory to understand and describe patient’s reports. Main outcome measure Experiences of receiving and delivering an enhanced HF service. Results Pharmacists voiced their confidence in delivering the service and highlighted valued aspects including the structured consultation and repeated contacts with patients enabling the opportunity to improve self care and medicines adherence. Discussing co-morbidities other than HF was difficult and persuading patients to modify behaviour was challenging. Patients were comfortable discussing symptoms and medicines with pharmacists; they identified pharmacists as fulfilling roles that were needed but not currently addressed. Patients reported the service helped them to enact HF medicines and HF self care management strategies. Conclusion Both patients receiving and pharmacists delivering a cognitive HF service felt that it addressed a shortfall in current care. There may be a clearly defined role for pharmacists in supporting patients to address the burden of understanding and managing their condition and treatment, leading to better self management and medicines adherence. This study may inform the development of strategies or policies to improve the process of care for patients with HF and has implications for the development of other extended role services.


Adherence Community pharmacy Heart failure Patient views Scotland Self-care 



Our friend and collaborator, Prof Steve Hudson, died during the course of this project. The authors are indebted to Steve for his general guidance, support and good humour.

Conflicts of interest

There are no conflicts of interest to report.


NHS Greater Glasgow and Clyde. The principal author’s time was funded by The National Research Scotland Fellowship Scheme.

Supplementary material

11096_2013_9889_MOESM1_ESM.docx (31 kb)
Supplementary material 1 (DOCX 31 kb)


  1. 1.
    Hobbs FD, Kenkre JE, Roalfe AK, David RC, Hare R, Davies MK. Impact of heart failure and left entricular systolic dysfunction on quality of life: a cross-sectional study comparing common chronic cardiac and medical disorders and a representative adult population. Eur Heart J. 2002;23(23):1867–76.PubMedCrossRefGoogle Scholar
  2. 2.
    Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013;127:e6–245.PubMedCrossRefGoogle Scholar
  3. 3.
    NHS Information Centre. National Heart Failure Audit 2010 [accessed 2nd Nov 2013]. Leeds: NHS IC. Available from:
  4. 4.
    Cleland JGF, Swedberg K, Poole-Wilson PA. Successes and failures of current treatment of heart failure. Lancet. 1998;352:SI19–28.PubMedGoogle Scholar
  5. 5.
    Rogers A, Addington-Hall JM, McCoy AS, Edmonds PM, Abery AJ, Coats AJ, et al. A qualitative study of chronic heart failure patients’ understanding of their symptoms and drug therapy. Eur J Heart Fail. 2002;4(3):283–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Chin M, Goldman L. Factors contributing to the hospitalization of patients with congestive heart failure. Am J Public Health. 1997;87(4):643–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Joynt KE, Whellan DJ, O’connor CM. Why is depression bad for the failing heart? A review of the mechanistic relationship between depression and heart failure. J Card Fail. 2004;10(3):258–71.PubMedCrossRefGoogle Scholar
  8. 8.
    Almeida OP, Flicker L. The mind of a failing heart: a systematic review of the association between congestive heart failure and cognitive functioning. Intern Med J. 2001;31(5):290–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Gottlieb SS, Khatta M, Friedmann E, Einbinder L, Katzen S, Baker B, et al. The influence of age, gender, and race on the prevalence of depression in heart failure patients. J Am Coll Cardiol. 2004;43(9):1542–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Jiang W, Alexander J, Christopher E, Kuchibhatla M, Gaulden LH, Cuffe MS, et al. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med. 2001;161(15):1849–56.PubMedCrossRefGoogle Scholar
  11. 11.
    Wong CY, Chaudhry SI, Desai MM, Krumholz HM. Trends in comorbidity, disability, and polypharmacy in heart failure. Am J Med. 2011;124(2):136–43.PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Wu JR, Moser DK, Lennie TA, Burkhart PV. Medication adherence in patients who have heart failure: a review of the literature. Nurs Clin N Am. 2008;43(1):133–53.CrossRefGoogle Scholar
  13. 13.
    van der Wal MH, Jaarsma T, van Veldhuisen DJ. Non-compliance in patients with heart failure; how can we manage it? Eur J Heart Fail. 2005;7(1):5–17.PubMedCrossRefGoogle Scholar
  14. 14.
    Lainscak M, Cleland JG, Lenzen MJ, Nabb S, Keber I, Follath F, et al. Recall of lifestyle advice in patients recently hospitalised with heart failure: a EuroHeart Failure Survey analysis. Eur J Heart Fail. 2007;9(11):1095–103.PubMedCrossRefGoogle Scholar
  15. 15.
    Naderi SH, Bestwick JP, Wald DS. Adherence to drugs that prevent cardiovascular disease: meta-analysis on 376,162 patients. Am J Med. 2012;125(9):882–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Williams A, Manias E, Walker R. Interventions to improve medication adherence in people with multiple chronic conditions: a systematic review. J Adv Nurs. 2008;63(2):132–43.PubMedCrossRefGoogle Scholar
  17. 17.
    Boswell KA, Cook CL, Burch SP, Eaddy MT, Cantrell CR. Associating medication adherence with improved outcomes: a systematic literature review. Am J Pharm Benefits. 2012;4(4):e97–108.Google Scholar
  18. 18.
    DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160(14):2101–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Sneed NV, Paul SC. Readiness for behavioural changes in patients with heart failure. Am J Crit Care. 2003;12(5):444–53.PubMedGoogle Scholar
  20. 20.
    Ambardekar AV, Fonarow GC, Hernandez AF, Pan W, Yancy CW, Krantz MJ, et al. Characteristics and in-hospital outcomes for nonadherent patients with heart failure: findings from Get With The Guidelines-Heart Failure (GWTG-HF). Am Heart J. 2009;158(4):644–52.PubMedCrossRefGoogle Scholar
  21. 21.
    Rich MW, Gray DB, Beckham V, Wittenberg C, Luther P. Effect of a multidisciplinary intervention on medication compliance in elderly patients with congestive heart failure. Am J Med. 1996;101(3):270–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Murray MD, Young J, Hoke S, Tu W, Weiner M, Morrow D, et al. Pharmacist intervention to improve medication adherence in heart failure: a randomized trial. Ann Intern Med. 2007;146(10):714–25.PubMedCrossRefGoogle Scholar
  23. 23.
    Bouvy ML, Heerdink ER, Urquhart J, Grobbee DE, Hoes AW, Leufkens HG. Effect of a pharmacist-led intervention on diuretic compliance in heart failure patients: a randomized controlled study. J Card Fail. 2003;9(5):404–11.PubMedCrossRefGoogle Scholar
  24. 24.
    NHS Quality Improvement Scotland. The coronary heart disease (CHD) Improvement Management Programme. CHD Resource Pack version 1. Edinburgh: NHS QIS; 2009. ISBN 0-7559-4376-7.Google Scholar
  25. 25.
    Scottish Intercollegiate Guidelines Network. Management of Chronic Heart Failure: A national clinical guideline. SIGN 95. Edinburgh: SIGN;2007. ISBN 1899893946.Google Scholar
  26. 26.
    National Institute for Health and Care Excellence. Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care. CG108. London: National Institute for Health and Care Excellence; 2008. ISBN 1-84257-323-3.Google Scholar
  27. 27.
    Ritchie J, Lewis J, editors. Qualitative Research Practice: A Guide for Social Science Students and Researchers. London: Sage; 2003 ISBN 0761971106.Google Scholar
  28. 28.
    Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2008;3(2):77–101.CrossRefGoogle Scholar
  29. 29.
    Daly J, Kellehear A, Gliksman M. The public health researcher: a methodological approach. Melbourne: Oxford University Press; 1997 ISBN 232324510.Google Scholar
  30. 30.
    Joffe H. Thematic Analysis. In: Harper D, Thompson AR, editors. Qualitative Research Methods in Mental Health and Psychotherapy: A Guide for Students and Practitioners Chichester: Wiley, 2011; ch15. doi:  10.1002/9781119973249.
  31. 31.
    Gallacher K, Morrison D, Jani B, MacDonald S, et al. Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research. PLoS Med. 2013;10(6):e1001473.PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    May C, Finch T. Implementing, embedding, and integrating practices: an outline of Normalization Process Theory. Sociology. 2009;43(3):535–54.CrossRefGoogle Scholar
  33. 33.
    Gallacher K, May CR, Montori VM, Mair FS. Understanding patients’ experiences of treatment burden in chronic heart failure using normalization process theory. Ann Fam Med. 2011;9(3):235–43.PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Molloy GJ, O’Carroll RE, Witham MD, McMurdo MET. Interventions to enhanced adherence to medications in patients with heart failure: a systematic review. Circ Heart Fail. 2012;5(1):126–33.PubMedCrossRefGoogle Scholar
  35. 35.
    Milfred-LaForest SK, Chow SL, DiDomenico RJ, Dracup K, Ensor CR, Gattis-Stough W, et al. Clinical pharmacy services in heart failure: an opinion paper from the Heart Failure Society of America and American College of Clinical Pharmacy Cardiology Practice and Research Network. J Card Fail. 2013;19(5):354–69.PubMedCrossRefGoogle Scholar
  36. 36.
    Alston CL, Paget GC, Halvorson B, Novelli B, Guest J, McCabe P, et al. Communicating with patients on health care evidence. Discussion paper. 2012 [Accessed Nov 2nd 2013]. Washington DC: Institute of Medicines. Available at:
  37. 37.
    Sanders T, Harrison S, Ckeckland K. Evidence based medicine and patient choice: the case of heart failure care. J Health Serv Res Policy. 2008;13(2):103–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Greenhill N, et al. Analysis of pharmacist-patient communication using the Calgary-Cambridge guide. Patient Educ Couns. 2011;83(3):423–31.PubMedCrossRefGoogle Scholar
  39. 39.
    Clark AM, McMurray JJV, Morrison CE. A qualitative study of the contribution of pharmacists to heart failure management in Scotland. Pharm World Sci. 2005;27(6):453–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Jani B, Blane D, Brown S, Montori VM, et al. Identifying treatment burden as an important concept for end of life care in those with advanced heart failure. Curr Opin Support Palliat Care. 2013;7:3–7.PubMedCrossRefGoogle Scholar
  41. 41.
    Chambers JA, O’Carrol RE, Hamilton B, Whittaker J, et al. Adherence to medication in stroke survivors: a qualitative comparison of low and high adherers. Br J Health Psychol. 2010;16:592–609.PubMedCrossRefGoogle Scholar
  42. 42.
    Bayliss EA, Steiner JF, Crane LA, Main DS. Descriptions of barriers to self care by persons with comorbid chronic diseases. Ann Fam Med. 2003;1:15–21.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Dolan-Mullen P, Green LW, Persinger GS. Clinical trials of patient education for chronic conditions: a comparative meta-analysis of intervention types. Prev Med. 1985;14:753–81.CrossRefGoogle Scholar
  44. 44.
    Correspondent Scotland. New remuneration structure on the cards in Scotland. Pharm Journal. 2013;290:628.Google Scholar
  45. 45.
    Blalock SJ, Roberts AW, Lauffenburger JC, Thompson T, O’Connor SK. The effect of community pharmacy-based interventions on patient health outcomes: a systematic review. Med Care Res Rev. 2013;70(3):235–66.PubMedCrossRefGoogle Scholar
  46. 46.
    Gidman W, Ward P, McGregor L. Understanding public trust in services provided by community pharmacists relative to those provided by general practitioners: a qualitative study. BMJ Open [online journal]. 2012;2(3):3000939 [Accessed 2nd Nov 2013];2(3). Available at:
  47. 47.
    Salter C, Holland R, Harvey I, Henwood K. “I haven’t even phoned my doctor yet”. The advice giving role of the pharmacist during consultations for medication review with patients aged 80 or more: qualitative discourse analysis. BMJ. 2007;334:1101–4.PubMedCrossRefGoogle Scholar
  48. 48.
    Mullen PD, Simons-Morton DG, Ramírez G, Frankowski RF, Green LW, Mains DA. A meta-analysis of trials evaluating patient education and counseling for three groups of preventive health behaviors. Patient Educ Couns. 1997;32(3):157–73.PubMedCrossRefGoogle Scholar
  49. 49.
    Lowrie R, Mair F, Greenlaw N, Forsyth P, Jhund P, McConnachie A, Rae B, McMurray JJV. Pharmacist intervention in primary care to improve outcomes in patients with left ventricular systolic dysfunction. Eur Heart J. 2011;33(3):314–24.PubMedCrossRefGoogle Scholar
  50. 50.
    McAlister FA, Stewart S, Ferrua S, McMurray JJV. Multidisciplinary strategies for the management of heart failure patients at high risk of admission: a systematic review of randomised trials. J Am Coll Cardiol. 2004;44(4):810–9.PubMedGoogle Scholar
  51. 51.
    Carter BL, Rogers M, Daly J, Zheng S, James PA. The potency of team based care interventions for hypertension: a meta analysis. Arch Intern Med. 2009;169:1748–55.PubMedCentralPubMedGoogle Scholar
  52. 52.
    NHS Scotland. Building a Health Service Fit for the Future. A National Framework for Service Change in the NHS in Scotland. Edinburgh: Scottish Executive; 2005. ISBN 0755946693.Google Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2013

Authors and Affiliations

  • Richard Lowrie
    • 1
    Email author
  • Lina Johansson
    • 2
  • Paul Forsyth
    • 1
  • Stuart Lochhead Bryce
    • 1
  • Susan McKellar
    • 2
  • Niamh Fitzgerald
    • 3
  1. 1.Research and Development, Pharmacy and Prescribing Support UnitNHS Greater Glasgow and ClydeGlasgowUK
  2. 2.Strathclyde Institute of Pharmacy and Biomedical SciencesStrathclyde UniversityGlasgowUK
  3. 3.Create Consultancy Ltd.GlasgowUK

Personalised recommendations