Abstract Body (Do not enter title and authors here): Hypothesis: Use of guideline-directed medical therapy for heart failure (HF) remains suboptimal. Prior trials demonstrated pharmacist management improves HF therapy use, but pharmacist HF management remains rare. We hypothesized audit and feedback increases HF medication optimization by primary care pharmacists.

Study Design and Methods: Randomized quality improvement.

Sample Size: 120 pharmacists responsible for 7,378 patients with HF across 345 primary care teams.

Population Studied: Veterans Affairs (VA) primary care pharmacists eligible for HF management across Northern and Central California, Nevada, and the Pacific Islands.

Intervention: We randomized pharmacists 1:1:2 to three arms: audit and feedback (AF), AF with targeted patient information (AF+), and usual care (UC). Each arm received access to monthly educational sessions and resources on HF medications. Pharmacists randomized to AF/AF+ received monthly emails with the number of HF medication actions over the prior 3 months with site-level and regional comparisons and HF medication rates. Pharmacists randomized to AF+ received lists of patients eligible for HF medication titration.

Primary Endpoints: The primary outcome was the difference in the rate of HF medication adjustment encounters between the combined AF/AF+ arms and UC during the post-blanking evaluation period 3-6 months post-randomization.

Secondary Endpoints: HF patients treated, percent of patients prescribed each class of HF therapy.

Power Calculations: At least 110 pharmacists had over 98% power to identify an increase of 1 HF encounter per month.

Results: Of 120 primary care pharmacists, 28 were randomized to AF, 30 to AF+, and 62 to usual care. Pre-intervention, each pharmacist averaged 2.1 encounters per month related to HF and 0.4 encounters with HF medication adjustment. During the evaluation period, between January 2024 and May 2024, pharmacists randomized to AF/AF+ had 1.2 (95% CI: 0.8-1.7, p<0.01) additional monthly HF encounters and 0.2 (95% CI: 0.1-0.4, p=0.01) additional encounters with HF medication adjustment (Figures 1-2). There were no significant differences between AF and AF+ arms.

Patients with HF in clinics with AF/AF+ pharmacists were more likely to receive new mineralocorticoid receptor antagonist prescriptions (11.3% vs. 9.0%; p=0.01). There were no other significant differences in HF medication prescriptions.

Conclusions: Audit and feedback is an effective approach to increasing pharmacist HF medication management.