The recently published BMJ Open Heart research paper on re-engineering the post-myocardial infarction (MI) medicines optimisation pathway presents a new and novel way of maximising patient benefits from their medicines and meeting their needs through multidisciplinary working.
The new model was very well received by patients and offers them a great opportunity to identify and discuss any actual and potential barriers to taking their secondary prevention medicines post-MI.
The new approach has several innovative elements that should be appreciated. Firstly, it involves triaging patients who have suffered an MI to see a cardiologist, a consultant cardiology pharmacist or both, depending on their needs. Patients who need no further non-pharmacological interventions see the consultant cardiology pharmacist (with the option of a review by a cardiologist if needed), while patients requiring further interventions such as staged percutaneous coronary intervention see a cardiologist (with the option of referral to the consultant pharmacist if needed).
Consultations typically last around 20 minutes, but individuals with more complex issues – such as known or elevated risk for poor adherence – can attend an enhanced session that lasts around 45 minutes.
Using this triaging model is efficient and evaluations showed that 95 percent of patients who were seen by the consultant pharmacist did not need to be seen by the cardiologist. This has created massive capacity within the outpatient clinics and has cut the waiting time to be seen post-MI in outpatients by almost a half.
The service has created massive capacity within the outpatient clinics and has cut the waiting time to be seen in outpatients by almost half.
Secondly, the new service uses a locally designed questionnaire called ‘My experience of taking medicine’ (MYMEDS). The questionnaire is completed by patients before attending clinic, and then discussed during clinic. The MYMEDS probes for actual and potential barriers to adherence and enables patients to raise and discuss any concerns or issues they have about their secondary prevention medicines. This novel approach enables the delivery of a consultation which is patient-centred and based on shared decision making. By the end of the consultation, patients are given a clear medicines and risk optimisation plan which is shared with their GP and cardiac rehabilitation team where applicable.
Thirdly, patient satisfaction with the format and being seen and reviewed by a consultant pharmacist was refreshing. All patients who answered the evaluation forms felt reassured by the pharmacist and reported that they were listened to, their concerns about their medicines were addressed, and that they were involved in the discussions and the decisions made about their medicines and risk optimisation. All patients agreed that the clinic was a valuable clinic that they would recommend for patients with heart disease.
The outcomes from the evaluation of this pharmacist-led medicines optimisation service are impressive:
- Levels of medicines optimisation were improved substantially. For example, ACE inhibitors optimisation significantly increased from 16 percent to almost 80 percent, and beta blockers optimisation increased from 6 percent to 46 percent
- Patients’ concerns about their medications were significantly decreased
- Rates of non-adherence decreased substantially in patients who attended the medicines optimisation clinic. In addition, the rate of prescription non-persistence in patients attending the clinic was 10 percent at 11–12 months post-MI discharge, compared with 34 percent in those who had not attended the clinic
- Readmission rates with acute coronary syndrome or chest pain up to 60 days post-discharge were reduced by almost half compared with rates before the introduction of the service
- Persistence with guidelines recommended secondary prevention medicines at 12 months post-discharge improved significantly.
- The medicines optimisation clinic led to a 44 percent reduction in mean waiting times from discharge to first outpatient cardiology review. The majority of patients were seen only by the consultant cardiology pharmacist, with fewer than 5 percent requiring input from a cardiologist.
The authors of the published study conclude that the results demonstrate that a medicines optimisation and patient adherence strategy based on a primarily pharmacist-led clinic supported by a cardiologist can improve both adherence and outcomes post-MI.
Cardiologists at Leeds Teaching Hospitals NHS Trust have welcomed this collaboration and the service has gained such popularity that two additional pharmacists are being trained to support the expanding clinics. There are also plans to support pharmacists who are interested in running a similar service in their Trusts.