Ask the Experts: Teaming Up for Interprofessional Heart Failure Care · 2020. 4. 22. · Ask the Experts: Teaming Up for Interprofessional Heart Failure Care. Proceedings from a live

Provided by ASHP Supported by an educational grant from Novartis

Ask the Experts: Teaming Up for Interprofessional Heart Failure Care

Proceedings from a live webinar originally presented 3/17/2020 | Released 5/1/2020 | Expires 5/1/2021

FACULTY Vicki Groo, Pharm.D., Activity Chair Clinical Associate Professor Pharmacy Practice University of Illinois at Chicago Clinical Pharmacists UI Health Heart Center Chicago, Illinois

Christopher P. Gans, MD, FACC Assistant Professor of Clinical Medicine Medical Director of Echocardiography University of Illinois at Chicago Chicago, Illinois

View faculty bios at www.ashpadvantage.com/hfcare

ACCREDITATION The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy

Education as a provider of continuing pharmacy education.

ACPE #: 0204-0000-20-401-H01-P 1.0 contact hour, Application-based

FINANCIAL DISCLOSURE STATEMENT Planners, presenters, reviewers, ASHP staff, and others with an opportunity to control CE content are required to disclose relevant financial relationships with ACCME-defined commercial interests. All actual conflicts of interest have been resolved prior to the continuing education activity taking place. ASHP will disclose financial relationship information prior to the beginning of the activity.

A relevant financial relationship is a defined as a financial relationship between an individual (or spouse/partner) in control of content and a commercial interest, in any amount, in the past 12 months, and products and/or services of the commercial interest (with which they have the financial relationship) are related to the continuing education activity.

An ACCME-defined commercial interest is any entity producing, marketing re-selling, or distributing healthcare goods or services consumed by, or used on, patients. The ACCME does not consider providers of clinical serve directly to patients to be commercial interests—unless the provider of clinical service is owned, or controlled by, an ACCME-defined commercial interest.

http://www.ashpadvantage.com/hfcare

Vicki Groo, Pharm.D., BCCP, CHC

Clinical Associate Professor, Pharmacy PracticeUniversity of Illinois at ChicagoClinical PharmacistUI Health Heart Center

Christopher P. Gans, M.D., FACC, FASE

Director, Onco‐Cardiology ProgramMedical Director, Echocardiography LabAssistant Professor of Clinical MedicineUniversity of Illinois Hospital & Health Sciences System

Provided by ASHPSupported by an educational grant from Novartis Pharmaceuticals Corporation


1.0 hr CE

Disclosure of Relevant Financial Relationships

Christopher Gans: Speakers Bureau, Pfizer

All other planners, presenters, reviewers, ASHP staff, and others with an opportunity to control content report no financial relationships relevant to this activity.

©2020 American Society of Health-System Pharmacists, Inc. All rights reserved.

2

• Describe guideline‐directed medical therapy (GDMT) for patients with heart failure, including the role of newer agents.

• Outline the pharmacist's role on an interprofessional team caring for patients with heart failure.

• Using case scenarios, illustrate key considerations in providing interprofessional care to patients with heart failure.

Learning Objectives

Abbreviations• ACEi ‐ angiotensin converting enzyme inhibitor• ACC ‐ American College of Cardiology• ADL ‐ activities of daily living• AHA ‐ American Heart Association• APRN ‐ advanced practice registered nurse• ARB ‐ angiotensin receptor blocker• ARNI ‐ angiotensin receptor blocker neprilysin inhibitor• BB ‐ beta‐blocker• BID ‐ twice daily dosing• BNP ‐ brain natriuretic peptide• BP ‐ blood pressure• bpm ‐ beats per minute• CI ‐ confidence interval• CKD ‐ chronic kidney disease• CrCl ‐ creatinine clearance • DOE ‐ dyspnea on exertion• EF ‐ ejection fraction• ESC ‐ European Society of Cardiology• ICD ‐ internal cardiac defibrillator

• FC ‐ functional class• HF ‐ heart failure• HFrEF ‐ heart failure with reduced ejection fraction• HFSA ‐ Heart Failure Society of America• HR ‐ heart rate• IV ‐ intravenous• MRA ‐ mineralocorticoid receptor antagonist• NT‐proBNP ‐ N‐terminal pro b‐type natriuretic peptide• NYHA ‐ New York Heart Association• PCP ‐ primary care provider• PND ‐ paroxysmal nocturnal dyspnea• SBP ‐ systolic blood pressure• TOC ‐ transition of care• VT ‐ ventricular tachycardia• UI Health ‐ University of Illinois Hospital

All medications referred to within presentation involve the oral route of administration unless otherwise stated


3


?If you participated in our previous heart failure activity, what changes have you made in your practice since then? (Select all that apply)

a. Read the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment.

b. Read the 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure Web Addenda (focusing on guides for managing problems with ACEi, ARB, beta‐blockers, and MRA)

c. Compare my organization’s protocols with the most up to date heart failure treatment guidelines.

d. Develop a plan to evaluate my organization’s utilization of GDMT for HFrEF in the ambulatory setting.

e. Determine the feasibility of pharmacist involvement in the ambulatory management of heart failure.

Pharmacist Managed Heart Failure Drug Therapy Titration Clinic



4


HFrEF GDMT in the Real WorldUse of GDMT (%)

Study Dates N ACEi/ARB/ARNI Beta‐blocker MRA Dual Triple

CHAMP HFa 2015‐2017 3,518 73 67 33 22

Target Dose Achieved <30 <30 >75 1

Utah Health 2007‐2013 989 69 79 28 58 19

Target dose Achieved 31 24 13

ESC Registry Ambulatory HF 2011‐2013 4,792 92 93 67

Target Dose Achieved 29 17 30

Use of GDMT prior to ICDb 2007‐2011 78,665 61

a Cardiologists better at prescribing GDMT than Gen Med but not at achieving target doseb GDMT associated with ↓ mortality (11.1 vs. 16.2%)

Green SJ et al. J Am Coll Cardiol. 2018; 72:351‐66. Bress AP et al. Pharmacotherapy. 2016; 36:174‐86.

Maggioni AP et al. Eur J Heart Fail. 2013; 15:1173‐84. Roth GA et al. J Am Coll Cardiol. 2016; 67:1062‐69.

• Which patients do you want to target?– Clinically stable only or include hospital TOC– Referral source (cardiology only or include PCP)

• Delineate the pharmacists role– Full assessment vs. medication reconciliation only

• Collaborative practice agreement vs. protocol• http://symposia.ashp.org/lms/content/hfcare/

Pharmacist HF Medication Titration Clinic


5


• Pharmacist has own schedule within the Heart Center templates– Electronic order available: “Refer to Pharm.D. for medication titration”

– 30 minute appointments– 7 to 8 patients 2 mornings a week

• Patients are discharged from Pharm.D. clinic once goals are achieved• Target or maximum tolerated dose, BP at goal

Pharmacist Titration ClinicUI Health Scheduling

• About 480 HF patients in the UI Health Heart Center– Titration may occur during M.D. appointments

• HF M.D. has a pharmacist• APRN also available for titration

• General cardiologist support during titration clinic– 2 M.D.s have their own clinic at same time as pharmacist– Consult as needed

• Exam for volume overload• Opinion on more complex cases

Pharmacist Titration ClinicPatient Volume and Clinician Support


6


• Pharmacist salary; financial sources– College of Pharmacy, Pharmacy Practice (75%)– Section of Cardiology, Heart Center (25%)

• Hospital‐based clinic– Professional fee—none at this time

• Provider Status recognition in your state– Technical or facility fee

• Money collected goes to the Heart Center• Based on face‐to‐face time with patient and number of medications reviewed

Pharmacist Titration ClinicBilling for Services at UI Health

UI HealthHeart Center Billing• Final intervention

level determined by billing specialist

• No way to separate pharmacist interventions from interventions entered by other personnel


7


• The service must take place in a “non‐institutional setting”• Continued physician‐patient relationship

– Relationship between physician and patient must be established– Medicare credentialed physician must personally perform the initial

service for each new condition, initial diagnosis, and plan of care

• Incident to billing is prohibited if:– >50% of service is counseling or coordination of care– Involves performing diagnostic tests

Shay DF. Using Medicare “Incident‐To” Rules. Fam Pract Manag. 2015; 22:15‐7.

Pharmacist Titration ClinicBilling: “Incident To” Criteria

• Direct Supervision – Provider present in the same building and immediately available – Provider is prepared to step in and perform the service– Provider is “clinically appropriate” to supervise the service– Provider is defined as physician or non‐physician provider (NPP)

• CPT code 99211‐99215

Shay DF. Using Medicare “Incident‐To” Rules. Fam Pract Manag. 2015; 22:15‐7.

Pharmacist Titration ClinicBilling: “Incident To” Criteria

Consult with administration, practice manager


8


UIC HF Medication Titration Clinic

Bhat S et al. Ann Pharmacother. 2018; 52:724‐32.

•HFrEF•Exclude transitions of care

Referral to Pharm.D.

Progress notes and prescription to M.D. for co‐signature

30 min appt.

•target or maximum tolerated dose achieved

•BP at goal

discharge to

referring M.D.

Follow up every 2 weeks

AssessmentHF ± hypertension medication titrationEducation

M.D. available as needed

Case Study: Discharge / Transition of Care

Christopher Gans, M.D., FACC, FASE


9


2017 ACC/AHA/HFSA HF Guidelines

Yancy CW et al. Circulation. 2017; 136:e137–61.

NYHA FC II‐IVCrCl >30 mL/min &

K <5 mEq/L

MRA

Add

Sacubitril/valsartan

Switch ACEi/ARB

NYHA FC II‐III Adequate BP

No contraindications

ACEi or ARB and GDMT BB titrated to target doseDiuretic as needed

Persistent Symptoms

NYHA FC I‐IVHFrEF

ISDN = isosorbide dinitrate, k = potassium

NYHA FC III‐IV African American

Hydralazine with ISDN

NYHA FC II‐III HR >70 bpm in sinus rhythm

Ivabradine

AddAdd

BC is a 55‐year‐old African‐American male diagnosed 3 months ago with non‐ischemic cardiomyopathy (EF 25%). He was admitted 2 days ago for acute heart failure / volume overload. He was diuresed, is euvolemic, and is getting ready for discharge.Home Meds (taken orally): Vital signs:

Carvedilol 6.25 mg BID BP 118/64 mm HgDigoxin 0.25 mg daily HR 86 bpmEnalapril 5 mg BID Pertinent Labs:Furosemide 40 mg BID Na: 136 mEq/L / K: 4.2 mEq/L

BUN: 42 mg/dL (baseline 30)Current Meds: SCr: 1.6 mg/dL (baseline 1.3)As above except furosemide is 80 mg IV BID

Patient Case

Na = sodium, BUN = blood urea nitrogen, SCr = serum creatinine


10


?What is your plan for transitioning from IV to oral diuretic?

a. Furosemide 40 mg BID and discharge tomorrowb. Furosemide 80 mg BID and discharge todayc. Furosemide 80 mg BID and discharge tomorrowd. Furosemide 40 mg BID + metolazone 2.5 mg

daily and discharge tomorrow

• Repeat congestion is dominant in HF readmissions– Inadequate dosing at the time of discharge– Kidney dysfunction may lead to underdosing of diuretics

• Transient worsening of SCr during effective decongestion does not lead to long‐term decrements in kidney function

• ↓ diuretic responsiveness in more advanced CKD• Consider prior home regimen & IV dosing required to achieve

negative fluid balance– Home 40 mg PO BID / Hospital 80 mg IV BID– No issues with non‐adherence to meds/diet identified

• Stable oral diuretic regimen for 24 hoursLindfield J. J Cardiac Fail. 2010; 16:e1‐e194.

Hollenberg SM et al. J Am Col Cardiol. 2019; 74:1966‐2011.

Acute Decompensated HF (ADHF) Transitioning diuretics


11




BUN: 42 mg/dL (baseline 30)Current Meds: SCr: 1.6 mg/dL (baseline 1.3)As above except furosemide is 80 mg IV BID

Patient Case

?What is your plan for his enalapril?

a. Hold, can restart as outpatientb. Continue 5 mg BIDc. Increase to 10 mg BIDd. Change to valsartan 80 mg BID


12


?What is your plan for his carvedilol?

a. Decrease to 3.125 mg BIDb. Continue 6.25 mg BIDc. Increase to 12.5 mg BIDd. Increase to 25 mg BID

• Prior therapies withheld?– Attempt re‐initiation

• No available data to guide plan• Consider restarting at lower doses based on objective and clinical data

• Prior therapies not at target?– Opportunity to increase dose / confirm tolerability

• Prior therapies at target?– Consider additional GDMT (i.e., ARNI, MRA, hydralazine/ISDN)


ADHF: Optimization of GDMT


13


• No clear reason for ADHF identified other than underuse of GDMT

• ACEi– BUN: 42 mg/dL (baseline 30) / SCr: 1.6 mg/dL (baseline 1.3)– Diuretic dose being increased– Defer increase in ACEi until labs rechecked as outpatient

• Beta‐blocker– BP stable but is tachycardic with HR of 86 bpm– Volume overload resolved

ADHF: Optimization of GDMT

Copernicus sub‐study: carvedilol vs. placebo in NYHA FC IV Patient outcomes during the first 8 weeks of treatment Decrease mortality in high‐risk patients (3 vs. 15, Hazard Ratio 0.2, CI 0.06‐0.7)

Numerically lower mortality, hospitalizations in all randomized patients

IMPACT‐HF: Pre‐discharge vs. post‐discharge (>2 weeks at M.D. discretion) initiation of

carvedilol Beta‐blocker use at 60 days: 91.2% pre‐discharge vs. 73.4% post‐discharge

(p <0.0001) Pre‐discharge more likely to be on target dose

No increase in adverse effects

Krum H et al. JAMA. 2003; 289:712‐18. Gattis WA et al. J Am Coll Cardiol. 2004; 43:1534‐41.

ADHF: Optimization of Beta‐Blockers


14


• When to initiate– In patients hospitalized with worsening HF – after stabilizing, relieving congestion, and, if possible, restoring ‘euvolemia’ (but ideally before discharge).

• Troubleshooting: Asymptomatic low BP– Does not usually require any change in therapy.

Ponikoski P et al. Eur Heart J. 2016; 37:2129‐200.

ADHF: Optimization of Beta‐Blockers

Why are target doses of GDMT important?

Ouwerkerk W et al. Eur Heart J. 2017; 38:1883‐90.

• BIOSTAT CHF: 2100 HFrEF patients followed for median 21 months• Achieving <50% of target dose = ↑ risk of death and HF hospitaliza on


15


?What is your plan for his digoxin?(height 70 inches, weight 80 kg, SCr 1.3 mg/dL)

a. Continue 0.25 mg dailyb. Decrease to 0.125 mg dailyc. Discontinue

• Added to standard of care in symptomatic HFrEF– Level of Evidence B, Class IIa (2013) – Not addressed in 2017 guideline update

• Clinical benefits– Decreases hospitalization but No effect on mortality

– Unknown whether these benefits exist in setting of current GDMT• Study population received only ACEi, diuretic; very few on beta‐blocker

• ACC: ADHF document– May be considered in advanced disease for symptomatic relief

Yancy CW et al. Circulation. 2013; 128:e240‐327. Yancy CW et al. Circulation. 2017; 136:e137‐61. Hollenberg SM et al. J Am Col Cardiol. 2019; 74:1966‐2011.

Guideline Recommendation: Digoxin


16




BUN: 30 mg/dL (improved from 42)Current Meds: SCr: 1.3 mg/dL (improved from 1.6)As above except furosemide is 80 mg IV BID

Clinical Curveball #1

?What is your plan for his enalapril?

a. Continue 5 mg BIDb. Increase to 10 mg BIDc. Change to sacubitril/valsartan 26/24 mg BIDd. Change to sacubitril/valsartan 49/51 mg BID


17


• ADHF (EF <40%) with elevated natriuretic peptide levels• Hemodynamically stable

– SBP ≥100 mm Hg – No ↑ in diuretics or use of IV vasodilators in prior 6 hours

• Randomized to sacubitril/valsartan or enalapril; dose based on BP– SBP 100 ‐ <120 mm Hg: 24/26 mg or 2.5 mg BID– SBP ≥120 mm Hg: 49/51 mg or 5 mg BID

• 3 doses prior to discharge– Will the M.D. agree to this vs. close follow up at home?

Velazquez EJ et al. N Engl J Med. 2019; 380:539‐48.

Inpatient Initiation of ARNIPIONEER HF

• Follow up for 8 weeks• 52% not on ACEi or ARB at time of admission• No safety issues identified• Greater reduction in NT‐proBNP with sacubitril/valsartan than enalapril– 55.2% sacubitril/valsartan and 60.8% enalapril patients on target dose at week 8

Velazquez EJ et al. N Engl J Med. 2019; 380:539‐48.

Inpatient Initiation of ARNIPIONEER HF


18


ARNI Dosing: FDA label

Entresto (sacubitril/valsartan) prescribing information. Novartis Pharmaceuticals Corp. 2019 Oct.

ACEi or ARB Dose Sacubitril/valsartan Initial Dose

None or low dose 24/26 mg BID

Target or maximum dose 49/51 mg BIDClinical characteristicSevere renal impairmentModerate hepatic impairment

24/26 mg BID

History of angioedema ContraindicatedDouble every 2‐4 weeks to target of 97 mg /103 mg BID

ACEi to ARNI: WAIT 36 HOURS

• Take ACEi from patient• Cancel ACEi prescription at

the pharmacy

ARB to ARNI: • Start when next dose

normally due

PIONEER dose plan is based on BP If already taking ACEi, will delay discharge

Transitioning to Outpatient Care and Pharm.D. Titration Clinic



19


?No clear etiology of acute HF identified. Attributed to inadequate treatment. What is your priority for discharge education? (Select all that apply)

a. Low sodium dietb. Recognition of HF symptomsc. Medication adherenced. Daily weightse. Changes to medication regimen

• 100 stroke patients received stroke education mandated by Joint Commission

• Average age of 60 years, 57% male, 56% African American, 43% urban dwelling, 75% low income, 59% low health literacy

• Stroke knowledge retention– Name all 5 stroke warning signs (12%) / call 911 (85%)– Personal risk factors for stroke (43%)– Medications prescribed for stroke (76%)

Schnepel L et al. Stroke. 2012; 43:A2954.

Health Education Retention


20


• Signs and symptoms– American Heart Association Rise Above Heart Failure Self‐Check Plan for

HF Management – VA Northern California KRAMES Patient Education. Heart Failure: Warning

Signs of a Flare‐up• Daily weights

– Provide a weight chart with instruction on when/whom to call for weight changes

• Medications– Provide an updated medication list including/highlighting changes to

regimen

Targeted Discharge Education

American Heart Association Rise Above Heart Failure Self‐Check Plan for HF Management. www.RiseAboveHF.org https://www.heart.org/‐/media/data‐import/downloadables/4/6/a/hf‐symptom‐tracker‐

ucm_477328.pdf?la=en&hash=DC5458A777E03699F36906AFC6D3A30861F1060D


21


VA Northern California KRAMES Patient Education. Heart Failure: Warning Signs of a Flare‐uphttps://vanortherncalifornia.kramesonline.com/HealthSheets/3,S,82086

Pharm.D. Discharge Note

Brief Hospital SummaryPMH Discharge MedsDiscontinued Meds Vitals (Day of Discharge)Pertinent LabsProblem list with plan

Include recommendation of “next step” of HF care to be done at the follow‐up visit(s) (i.e., labs, medication titration)

• Pt case PharmD Discharge Note_2020.docx

• Sample CCU PharmD Discharge Note_2020 (1).docx

• Note content based on 2019 ADHF decision pathway; communication to continuing care providers



22


Patient Case (Continued)Transition of Care Visit

BC, a 55‐year‐old African‐American male, is 5 days post hospital d/c for ADHF and is at his TOC appointment with an APRN and Pharm.D. States edema is resolved but still with DOE walking around house/yard, cleaning/cooking. No PND, 3 pillow orthopnea is stable. No dizziness/syncope/palpitations.Medications: Labs:Carvedilol 12.5 mg BID BUN: 36 mg/dL(↓from 42, baseline 30)Enalapril 5 mg BID SCr: 1.4 mg/dL (↓from 1.6, baseline 1.3)Furosemide 80 mg BID K: 3.8 mEq/L (↓ from 4.4)

Vitals

BP: 116/62 mm HgHR: 78 bpm

?Which drug do you want to titrate today?

a. Increase carvedilol to 25 mg BIDb. Increase enalapril to 10 mg BIDc. Increase carvedilol to 25 mg BID and enalapril

to 10 mg BID


23


• Progress note / medication orders forwarded to referring provider for co‐signature– History of Present Illness– Objective data– Assessment/plan

• Plan includes reasoning for each recommendation– Increase enalapril to 10 mg BID as acute kidney injury now resolved, BP stable– Continue carvedilol 12.5 mg BID as just increased in hospital 6 days ago, HR

improved. Plan to titrate at next visit.

• Billing– 1‐5 medications– Patient assessment and education based on face‐to‐face time

Pharm.D. Visit Documentation

Patient was referred to Pharm.D. from TOC clinic for ongoing med titration. Enalapril increased at last visit. Patient with new complaints of dizziness. No edema, PND, DOE still with ADLs.Medications: Vitals:Carvedilol 12.5 mg BID BP: 98/56 mm Hg (was 116/62)Enalapril 10 mg BID HR: 88 bpm (was 78)Furosemide 80 mg BID

Patient Case (Continued)Pharm.D. Med Titration Visit


24


?What is your plan?

a. Order chemistry panelb. Decrease enalapril back to 5 mg BIDc. Decrease carvedilol back to 6.25 mg BIDd. Decrease furosemide back to 40 mg BID

Problem solving for symptomatic hypotension

• Dizziness/lightheadedness is common and often improves with time–patients should be reassured.

• Reconsider need for nitrates, calcium‐channel blockers, and other vasodilators and reduce dose/stop, if possible.

• If no signs or symptoms of congestion, consider reducing diuretic dose.

• If these measures do not solve problem, seek specialist advice.

• His dizziness is new and associated with drop in BP

• He is not taking nitrates or calcium channel blocker

• He has no signs of congestion. Labs will help determine whether excessive diuresis is cause of hypotension– It often takes a larger diuretic dose to

treat volume overload than to maintain euvolemia

Ponikoski P et al. Eur Heart J. 2016; 37:2129‐200.


25


?Labs are stable. What is your plan to manage his hypotension?

a. Decrease enalapril to 5 mg BIDb. Decrease carvedilol to 6.25 mg BIDc. Change enalapril to sacubitril/valsartan 24/26 mg

BIDd. Change carvedilol to metoprolol succinate 100 mg

daily

Clinical Curveball #2: BC, a 55‐year‐old African‐American has been referred to Pharm.D. from TOC for ongoing med titration. Enalapril increased at last visit. BP at home has been stable but he is reporting an episode of sudden onset severe dizziness but no syncope. His wearable defibrillator set off a loud alarm. You contact the manufacturer and get a report of event with non‐sustained ventricular tachycardia (NSVT). No edema or PND, still has DOE with ADLs. No PND, 3 pillow orthopnea is stable. Medications: Labs:Carvedilol 12.5 mg BID BUN: 36 mg/dL(↓from 42, baseline 30)Enalapril 10 mg BID SCr: 1.4 mg/dL (↓from 1.6, baseline 1.3)Furosemide 80 mg BID K: 4.2 mEq/L Vitals BP: 116/62 mm HgHR: 78 bpm


26


?In addition to electrophysiology referral, what is your plan?

a. Start amiodaroneb. Start spironolactonec. Increase carvedilol d. Increase enalaprile. Switch enalapril to sacubitril/valsartan

• Beta‐blockers and spironolactone decrease sudden death in addition to progression of HF

• Post‐hoc analysis of PARADIGM– Sacubitril/valsartan: significant ↓ in sudden death vs. enalapril

• Sacubitril/valsartan effect on arrhythmias– 120 patients on ACEi/ARB + beta‐blocker + MRA x 9 months– Changed all on ACEi/ARB to sacubitril/valsartan– Significant ↓ NSVT, sustained VT, ICD shocks vs. ACEi/ARB

Packer M et al. N Engl J Med. 1996; 334:1349‐55. Pitt B et al. N Engl J Med. 1999; 341:709‐17. Desai AS et al. Eur Heart J. 2015; 36:1990‐7. deDiego C et al. Heart Rhythm. 2018; 15:395‐402.

Ventricular Arrhythmias in HFrEF


27


• Transitioning from IV to oral diuretics• Improving GDMT before discharge• Improving GDMT at follow up• Managing new symptoms

Case Summary


28


Documents

Ask the Experts: Teaming Up for Interprofessional Heart Failure Care · 2020. 4. 22. · Ask the Experts: Teaming Up for Interprofessional Heart Failure Care. Proceedings from a live