Vol.2, No.9, 1087-1092 (2010) Health
doi:10.4236/health.2010.29160
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
How the community pharmacist contributes to the
multidisciplinary management of heart failure
E. Chauvelot1, V. Nerich1,2, S. Limat1,2, M. F. Seronde3, M. C. Woronoff-Lemsi1,2*
1Department of Pharmacy, University Hospital of Besançon, Besançon, France
2School of Medicine and Pharmacy, Besançon, France; *Corresponding Author:
3Department of Cardiology, University Hospital of Besançon, Besançon, France
Received 12 May 2010; revised 26 May 2010; accepted 3 June 2010.
ABSTRACT
Objective: To define how the community phar-
macist contributes to the management of heart
failure by exploring the type of service he pro-
vides to patients and by assessing what patients
expect from him. Setting: Pharmacists of the
Franche-Comte region (France) and patients of
the Franche-Comté Heart Association. Method:
Two questionnaires were drawn up and sent to
pharmacists and patients. Results: The 118
pharmacists participating in this survey (36.9%)
felt that they had a role to play in dispensing
drugs (100.0%), educating patients about their
treatment (83.1%), informing patients about the
importance of observance (81.4%) and over-
the-counter drugs (58.5%), distributing heart
failure brochures (51.7%) and providing medical
equipment (44.9%). On the other hand, only a
third of them thought that they should inform
patients about their illness and give advice by
phone. On the whole, knowledge level is good
for disease, drug therapy, contraindicated drugs,
medical supervision and hygieno-dietetic man-
agement, but intermediate or poor for alert signs
of decompensation, essential vaccinations and
patient associations. University training in this
area during formal pharmacy studies is consid-
ered either “insufficient” or “very insufficient”
in 56.9% of cases. Although more than 99% of
the pharmacists think that additional training is
needed, only 33.1% had actually benefited from
such training. Of the 96 patients (48.0%) who
completed the questionnaire, 92.6% are faithful
to their pharmacist. They contact him more
about drug therapy than about their disease, or
information related to treatments. Roles attrib-
uted to their pharmacist are mainly related to
drug therapy explanation and information con-
cerning over-the-counter drugs. Therapeutic
education is known to 40.6% of interrogated
patients. Among these patients, two-thirds de-
pend on their pharmacist and feel that he is
capable of providing the necessary education.
Moreover, 46.2% of patients had received some
form of therapeutic education from their phar-
macist. Pharmacists believe that they are able to
assume this role in 67.8% of cases. Conclusion:
In spite of biases, this study allowed us to as-
sess the expectations of heart failure patients
with regard to the pharmaceutical management
of their disease, thus clarifying the indispensa-
ble contribution that pharmacists make in the
management of this disease.
Keywords: Heart Failure; Management;
Community Pharmacist
1. BACKGROUND
Heart failure remains a common diagnosis and is an im-
portant public health problem [1]. The prevalence of
heart failure exponentially increases with advanced age
[2]. Depending on the severity of symptoms, heart dys-
function, age and other factors, heart failure can be asso-
ciated with an annual morbidity and mortality of 5% to
50% [2]. Although many causes of heart failure exacer-
bations requiring hospitalisation can be identified, medi-
cation and dietary noncompliance have been reported as
contributing factors in up to 33% of hospitalised patients
[3]. However major advances in both diagnosis and
management have occurred and will continue to improve
symptoms and patient outcomes [4-6].
A multidisciplinary approach to managing patients
suffering from heart failure has been shown to improve
outcome [7]. Yet the place and the role of the community
pharmacist in the multidisciplinary management of heart

E. Chauvelot et al. / HEALTH 2 (2010) 1087-1092
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
1088
failure have not been defined. Pharmacists may play a
role in drug dispensation, patient follow-up and moni-
toring of drug therapy. However, the role of the pharma-
cist could be extended.
Therefore, the aim of this study was to define how the
community pharmacist contributes to the management of
heart failure by exploring the type of service he provides
to patients and by assessing what patients expect from
him.
2. METHOD
2.1. Study Design
To achieve the aim of our study, we developed and sent
two anonymous questionnaires, first to pharmacists and
then to heart failure patients.
The first questionnaire, for pharmacists, was subdi-
vided into five parts: 1/pharmacist characteristics: per-
manent (yes or no), how long he has had his qualifica-
tions (< 5, (5-9), (10-14), > 15 years), pharmacy location
(country, city center, urban district, shopping center),
number of follow-up heart failure patients (0, (1-5),
(6-10), (11-15), > 15), faithful patients (yes or no); 2/
knowledge of heart failure (disease, alert signs of de-
compensation, drug therapy, contraindicated drugs, hy-
gieno-dietetic management, medical supervision, essen-
tial vaccinations, patient association) and role to play (in
dispensing drugs, educating patients about their disease
and treatment, informing patients about over-the-counter
drugs and the importance of observance, referring pa-
tients to other health professionals or patient/support
associations, providing medical equipment, giving ad-
vice by phone, distributing brochures about heart failure);
3/asked questions by patient: frequently (yes or no),
ability to answer (frequently, sometimes, rarely, never),
adopted behaviour if no answer (searching for answer in
documents, on internet, contacting the patient’s physi-
cian); 4/initial university training (very satisfactory, sat-
isfactory, insufficient, very insufficient) and continuing
education (necessary, yes or no); 5/therapeutic education:
knowledge (yes or no), investment and motivation to
provide it (yes or no), privacy space (yes or no).
This questionnaire was distributed to the pharmacists
of the Franche-Comté region, via three wholesale dis-
tributors. One pharmacist per pharmacy was allowed to
answer the questionnaire.
The second questionnaire, for patients, was subdi-
vided into three parts: 1/patient characteristics: age
(years), sex (female or male), duration of disease (years),
residence (city or country), faithfulness to community
pharmacist (yes or no) and grounds (good drug therapy
knowledge or good advice provided by pharmacist;
pharmacist listens attentively to patients and when nec-
essary refers them to other health professionals; prox-
imity of pharmacy, other); 2/roles and expectations re-
garding the way the pharmacist manages their disease: a)
how often patients ask questions about disease or drug
therapy (frequently, sometimes, rarely, never), pharma-
cists responses (very satisfactory, satisfactory, insuffi-
cient, very insufficient); b) good contact for any request
related to disease or drug therapy, information on over-
the-counter drugs, medical follow-up, medical supervi-
sion, hygienodietetic management, referral to other
health professionals or support/patient associations (yes
or no); 3/therapeutic education: knowledge (yes or no),
trust pharmacist to provide it (yes or no), in pharmacy
(yes or no).
This questionnaire with stamped envelope for return
was distributed to patients of Association de Cardiologie
de Franche-Comté (id est. Franche-Comté Heart Asso-
ciation).
Both questionnaires were accompanied by a letter ex-
plaining the aim of the study and instructions on how to
return the completed questionnaire. Questionnaires were
collected, centralized and analyzed.
2.2. Statistical Analysis
SAS 9.1® software was used for questionnaire analysis.
Continuous variables were described by mean  standard
deviation and median with ranges [minimum value –
maximum value] and qualitative variables by the number
and percentage. Quantitative and qualitative variables
were compared respectively by the Wilcoxon Mann-
Whitney and the Fisher exact test or the chi square test.
The tests were significant at an alpha threshold of 5%
(p).
3. RESULTS
3.1. Pharmacist Point of View
3.1.1. Pharmacist Characteristics
Out of the 320 distributed questionnaires, 118 (36.9%)
were analysed. Results revealed that pharmacists are
mainly permanent (75.4%) and have been qualified for
more than 15 years (57.7%). Permanent pharmacists
have been qualified longer than assistant pharmacists
(p < 10-4). More than half of the pharmacists work in
rural areas (53.8%) and others in urban districts, city
centers and shopping centers respectively in 23.1%,
19.7% and 3.4% of cases. On the whole, they provide
follow-up to more than ten heart failure patients
(70.1%). Heart failure patients tend to be very faithful
(96.6%).

E. Chauvelot et al. / HEALTH 2 (2010) 1087-1092
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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3.1.2. Knowledge of Heart Failure and Role to Play
Pharmacists’ assessment of their own knowledge of
heart failure is summarized in Table 1.
Their knowledge level with regard to drug therapy,
hygieno-dietetics, and essential vaccinations was sig-
nificantly related to the number of patient follow-ups in
the pharmacy (respectively, p = 0.04, p = 0.01 and p =
0.02). Pharmacists’ knowledge level increased with the
number of patients. Disease knowledge was significantly
positively related to drug therapy knowledge (p < 10-3),
contraindicated drugs and alert signs of decompensation
knowledge (p = 0.01).
Without taking into account drug dispensation
(100.0%), the pharmacist plays different roles in: edu-
cating patients about their treatment (83.1%), informing
them about the importance of observance (81.4%) and
over-the-counter drugs (58.5%), distributing brochures
about heart failure (51.7%) and providing medical
equipment (44.9%).
One-third of the pharmacists in our study also play a
role in educating patients about their disease (35.6%)
and providing advice by phone (33.0%). Referral to oth-
er health professionals and support/patient associations
was only found for respectively 22.0% and 11.0% of
pharmacists.
3.1.3. Questions Asked by Patients
Pharmacists estimated that more than a third of all pa-
tients (33.9%) often ask them questions. However,
pharmacists were unable to answer these questions in
69.1% of cases. There is no significant difference be-
tween the frequency of questions and the ability to an
Table 1. Pharmacist self-evaluation: Knowledge of heart failure.
Knowledge Level, number (%)
n = 118 Ve ry
Good Good Average Poor
Disease 4 (3.4) 68 (57.6) 43 (36.4) 3 (2.5)
Alert signs of
decompensation 6 (5.1) 36 (30.5) 55 (46.6) 21 (17.8)
Drug therapy 11 (9.3) 88 (74.6) 18 (15.3) 1 (0.9)
Contraindicated
drugs 11 (9.3) 59 (50.0) 42 (35.6) 6 (5.1)
Medical
supervision 5 (4.3) 51 (43.2) 51 (43.2) 11 (9.3)
Essential
vaccinations 3 (2.5) 34 (28.8) 48 (40.7) 33 (28.0)
Hygieno-dietetic
management 15 (12.7) 70 (59.3) 31 (26.3) 2 (1.7)
Patient
association 0 (0.0) 3 (2.5) 29 (24.6) 86 (72.9)
swer (p = 0.69). If the pharmacist cannot answer, imme-
diately, he tries to find the answer in documents (82.8%),
on internet (43.1%) or by contacting the patient’s physi-
cian directly (68.1%).
3.1.4. Initial University Training and Continuing
Education
Initial university training about heart failure was judged
satisfactory to very satisfactory by 43.1% of pharmacists.
More than 99% of them consider it necessary to have a
additional training. However, only 33.1% of pharmacists
ever actually had continuing education. The older the
qualifications, the more dissatisfied the pharmacist was
with his initial university training (p = 0.02) and the
more interested he was in additional training (p < 10-3).
Continuing education was also significantly positively
related to the number of heart failure patient follow-ups
in the pharmacy (p = 0.04), permanent pharmacist status
(p = 0.04), and how long the pharmacists has been quali-
fied (p < 10-3).
3.1.5. Therapeutic Education
77.1% of pharmacists participating in our study known
about therapeutic education and they think that they are
able to play this role in 67.8% of cases. More than
two-thirds (70.3%) have privacy space.
3.2. Heart Failure Patient Point of View
3.2.1. Patient Characteristics
Of the 200 questionnaires distributed to patients, 96
(48.0%) were collected and analysed. Patient character-
istics are summarized in Table 2. The mean age of dis-
ease was estimated at 8.3  0.9 years, with a median of 6
years (1-51).
Patients are faithful to their pharmacist in 92.6% of
cases for different grounds (Table 3). Patients living in
the city are significantly more faithful than patients liv-
ing in the country (p < 10-2). Listening and referral to
other health professionals are significantly related to the
sex of patients (p = 0.02): these roles are important for
Table 2. Heart failure patient characteristics.
n = 96 number (%)
Sex
Female
Male
31 (32.3)
65 (67.7)
Age classes (years)
< 60
(60–75)
> 75
12 (12.5)
64 (66.7)
20 (20.8)
Residence*
City
Country
60 (63.2)
35 (36.8)
Faithfulness to the pharmacy*
Yes
No
88 (92.6)
7 (7.4)

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Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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32.0% of male patients as opposed to only 9.8% of fe-
male patients.
3.2.2. Pharmacist Roles and Expectations
Regarding the Management of their
Disease
Patients contact their pharmacist mainly to ask questions
about drug therapy rather than about their disease (re-
spectively, 58.0% and 31.0% of cases). Reponses are
satisfactory or very satisfactory in 77.2% of cases. But
more than 15% of patients do not have an opinion.
Patients state that contact with their pharmacist is
good for any request of information related to treatments
(explanation, information on over-the-counter drugs)
(Table 4).
However, for disease explanation or medical follow-
up/supervision, attitudes differ. Men think that the phar-
macist has a role in medical follow-up and medical su-
pervision, whereas most women do not (respectively, p =
0.04 and p = 0.02).
3.2.3. Therapeutic Education
40.6% of patients indicated that they were familiar with
therapeutic education and this was not significantly re-
lated to the sex (p = 0.65) or age (p = 0.15) of patients or
to their place of residence (city or country, p = 0.35).
Among patients familiar with therapeutic education, two-
thirds (69.2%) depend on their pharmacist and think that
he can. Moreover, 46.2% of patients had received some
form of therapeutic education from their pharmacist.
4. DISCUSSION
Heart failure management is a public health priority. The
multidisciplinary approach to managing it has been
shown to improve outcome, in particular in terms of
hospitalisation [4-6,8]. However, the role of the commu-
nity pharmacist has not been evaluated. Since patients
always have to visit their pharmacy to collect their drug
therapy, it seems coherent to include community phar-
macists in multidisciplinary management. We therefore
felt that, by using two questionnaires, we could assess:
1/pharmacists: their knowledge of heart failure and their
Table 3. Grounds of faithfulness.
Grounds of faithfulness, n = 88 number (%)
Pharmacist’s good drug therapy knowl-
edge 57 (64.8)
Pharmacist’s good advices 33 (37.5)
Pharmacist’s ability to listen to and
refer patients to others health profes-
sionals
14 (15.5)
Proximity of pharmacy 69 (78.4)
Other 7 (8.0)
Table 4. Roles attributed to the pharmacist by heart failure
patients.
n = 96
Is the pharmacist quali-
fied and capable of provi-
ding necessary informa-
tion? number (%)
Disease explanation
Yes 20 (20.8)
No 76 (79.2)
Drug therapy explanation
Yes 68 (70.8)
No 28 (29.2)
Information on over-the
-counter drugs
Yes 55 (57.3)
No 41 (42.7)
Medical follow-up
Yes 36 (37.5)
No 60 (62.5)
Medical supervision
Yes 13 (13.5)
No 83 (86.5)
Hygieno-dietetic management
Yes 29 (30.2)
No 67 (69.8)
Referral to support
associations
Yes 9 (9.4)
No 87 (90.6)
Referral to others health
professionals
Yes 18 (18.8)
No 78 (81.2)
roles especially concerning their ability and willingness
to provide therapeutic education and 2/patients: roles
and expectations regarding pharmacist management of
their disease, and also whether or not they trust pharma-
cists to provide therapeutic education. Pharmacists and
patients included in this study constitute a specific sam-
ple. Thus, 320 of 437 community pharmacists of the
Franche-Comté region (73%) received a questionnaire
and 118 of them (37%) responded. Among patients of
the Franche-Comté Heart Association, 96 responded.
They were not representative of the total number of heart
failure patients (selection bias) because they have al-
ready accepted the disease and are willing to share their
experience with other patients. On the whole, we can
consider the patient response rate satisfactory, especially
since our study did not include a reminder or anonymous

E. Chauvelot et al. / HEALTH 2 (2010) 1087-1092
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follow-up mail to patients.
Heart failure patients, over sixty years old in 88% of
cases (over seventy-five years old in 21% of cases) are
satisfied with their community pharmacist and are faith-
ful to him. They express some expectations related to
their questions. To our knowledge, patient expectations
have never been studied. For most patients, the commu-
nity pharmacist is a drug therapy specialist (explanation
and information on over-the-counter drugs). However,
few patients (between 9% and 38%) think that the phar-
macist must play other roles such as: disease explanation,
medical follow-up, medical supervision, hygieno-dietetics
management, referral to support associations or to other
health professionals. A better integration and involve-
ment of the community pharmacist in the managing
heart failure patients could improve this image. Thus, for
example, in terms of public heath, collaboration between
support association/health professionals and community
pharmacists could be envisaged.
Efforts to promote adherence should be included in pro-
grams involving a multidisciplinary team with community
pharmacist participation designed to improve heart failure
therapy and outcomes. Pharmacists have an important role
to play in educating patients. Patient therapeutic education
is a vital component of heart failure management and re-
inforces the importance of medication adherence. Thus, in
spite of the fact that 59% of patients polled did not know
about therapeutic education, among those familiar with it,
two-thirds depend on their pharmacist and think that he is
capable of providing it. Moreover, 46.2% of patients had
received some form of therapeutic education from their
pharmacist. 77% of pharmacists polled know about thera-
peutic education and they feel that they are able to play this
role in 68% of cases. Therapeutic education ordinarily
takes place in a hospital setting. It would be interesting to
consider and promote the community pharmacy as an ad-
ditional setting.
Community pharmacist follow-up more than ten heart
failure patients and they tended to return regularly. In-
deed, community pharmacists are in a good position to
provide a local service. Their work should not be limited
to drug dispensation, but must include educating patients
about their treatment, informing about the importance of
observance and therapeutic education, and providing
medical equipment. However, community pharmacists
are not comfortable in all fields. Their initial university
training about heart failure was considered insufficient
or very insufficient by 57% of community pharmacists.
The older the qualifications, the more dissatisfied the
pharmacist was with his initial university training. This
could explain why pharmacists were unable to answer in
69% of cases when patients inquired about heart failure.
Almost all feel that it is necessary to have continuing
education, but only one-third have ever had it. An addi-
tional refresher course is essential to remedy this situa-
tion and to ensure an effective and competent participa-
tion in the multidisciplinary management of heart failure
patients.
The design of our study is original, exploring both the
pharmacist and the patient’s point of view. It is debatable
whether or not the present study results may be com-
pared with those obtained in the literature. Some studies
have assessed the role of the community pharmacist in
the management of heart failure [9-13]. Thus, Gattis et al.
show that heart failure outcomes can be improved with a
clinical pharmacist as an important component of the
multidisciplinary heart failure team [14]. Pharmacists
contribute to the overall care of these patients, but
should be appropriately trained. Murray et al. show that
pharmacist intervention for outpatients with heart failure
can improve adherence to cardiovascular medications
and decrease health care use and costs, but the benefit
probably requires constant involvement because the ef-
fect dissipates when the intervention ceases [13]. Phar-
macist received training for their intervention. The same
is true of the Bouvy et al. study [9].
In the United Kingdom, the government has been en-
couraging an extension to the role of community phar-
macists, including independent prescribing, medicine use
review and a health promotion role to provide advice
about, diet and nicotine addiction, among other issues
[15]. In the United Arab Emirates, the introduction of a
clinical pharmacy programme involving optimization of
drug treatment and intensive education and self-moni-
toring of patients [11]. In Canada, the involvement of
pharmacists in problems of patient compliance goes back
many years and has been studied through the PRECEDE
pharmacist education program which espouses a thor-
ough structured approach to patient education incorpo-
rating patient’s beliefs [16]. Community-based pharma-
cists are embedded in an infrastructure where they are
essential for patients to receive medication.
Pharmacist’s involvement in a disease management
program will improve the care given to patients with
heart failure.
5. CONCLUSIONS
In spite of biases, this study allows us to assess the ex-
pectations of heart failure patients with regard to the
pharmaceutical management of their disease, thus, clari-
fying the indispensable contribution that pharmacists
make in managing this disease.
6. ACKNOWLEDGEMENTS
We would like to thank all patients of the Franche-Comte Heart Asso-

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Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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ciation and the community pharmacists who contributed to this study.
We also thank Ms Pamela Albert for proofreading the manuscript.
7. CONFLICTS OF INTEREST
There is no potential conflict of interest related to the content of this
manuscript.
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