The potential of clinical pharmacy to improve patient health outcomes is yet to be fully realized in Africa as the practice remains scarce. In this paper, we highlight the current status, gaps, and opportunities for clinical pharmacy scale‐up in the region. Persistent gaps in clinical pharmacy practice include undergraduate and postgraduate curricula that are inadequate in producing practice‐ready clinical pharmacists. Experiential training is insufficient, and its effectiveness is limited by an inadequate number of trained clinical pharmacy preceptors at practice sites. At the institutional level, a lack of formalized job descriptions, low numbers of practicing clinical pharmacists, and lack of tools to facilitate documentation of clinical pharmacy activities and interventions pose practice challenges. Finally, there is inadequate policy and legislation to guide the increase of clinical pharmacy practice. Curriculum reform of the traditional Bachelor of Pharmacy (B.Pharm) program at the undergraduate level is needed to prepare pharmacy students for direct patient care roles. In addition, there is a need to increase Doctor of Pharmacy (Pharm.D.) programs and adopt innovative postgraduate programs for clinical pharmacist specialization, such as residencies and fellowships. Experiential training can be strengthened by making it longitudinal, and conducting it in practice sites with trained clinical pharmacy preceptors. At the level of hospital institutions, clear job descriptions need to be crafted for clinical pharmacists, and systems to facilitate documentation of their activities and interventions created. Finally, national policy and legislation on clinical pharmacy practice is needed to facilitate required training and practice reforms, and guide hospital implementation of clinical pharmacy practice.
Decompensated heart failure accounts for approximately 1 million hospitalizations in the USA each year with an estimated cost of US$11,000 per hospitalization. Despite this prevalence and cost burden, relatively few therapies for decompensated heart failure have been developed over the past 30 years. Although once the mainstay of treatment of decompensated heart failure, the use of positive inotropic agents has fallen into disfavor. Although these agents improve hemodynamics and ejection fraction, there is evidence that the positive inotropes increase the risk of adverse clinical outcomes and mortality. Nesiritide is a naturetic peptide that produces balance vasodilation, inhibits sympathetic nervous system activity, and promotes diuresis and naturesis. At the time the drug received Food and Drug Administration approval for marketing in the USA, it had been shown to produce hemodynamic improvements to an extent greater than placebo or nitroglycerin. However, evidence of benefit in terms of clinical improvement and other outcomes was lacking. Recent trials have found that nesiritide reduces hospital length of stay (although not statistically significant in all trials) and healthcare resource utilization in patients admitted to hospital with decompensated heart failure. In a randomized, controlled trial, nesiritide given in the emergency room reduced hospital admissions for heart failure compared with placebo/usual care. Preliminary data from an outpatient intermittent infusion trial of nesiritide found that patients receiving nesiritide had fewer hospital admissions than patients randomized to standard care. There is currently little objective evidence that therapies used routinely in the management of patients with decompensated heart failure are associated with improved outcomes. Data with positive inotropic agents suggest that they do more harm than good. There is a growing body of evidence that nesiritide is associated with improvements in clinical outcomes in decompensated heart failure including fewer complications, less healthcare resource utilization, and lower costs when compared with standard therapy. Despite this evidence, larger, prospective trials demonstrating the impact of nesiritide on the costs and complications in decompensated heart failure are needed.
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