Re-engineering the Post-Myocardial Infarction Medicines Optimisation Pathway

The aims and objectives of the project are:

• Building on research conducted in this field, the aim of the post MI medicines optimisation multidisciplinary clinics will be to provide a comprehensive medicines review for patients with cardiovascular disease who have recently suffered an MI and to test if this intervention improves patient outcomes.
• With the objective of enabling patients to share their medicines-taking experience and provide them with the necessary support to maximise their benefit from their medicines and reduce the risk for developing adverse drug reactions.
• The project objective will be to adopt a patient-centred approach and shared-decision making strategies to enable the establishment of true medicines partnership.

The project aims to improve implementation and adherence to CHD and medicines optimisation-related NICE guidance and quality standards including:

• Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease (NG185).
• Cardiovascular disease: risk assessment and reduction, including lipid modification (CG181).
• Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence (CG76).
• Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NICE guidelines (NG5).

The project will:

• Consider the need of additional support for some groups of cardiology patients who have been discharged from hospital.
• Ensure that the patient’s medicines are fully reconciled post discharge and any ambiguity is addressed.
• Carry out a structured medication review.
• Provide self-management plans which aim to support people to be empowered and involved in managing their condition.
• Evaluate polypharmacy, where present, and ensure that the patient is on appropriate polypharmacy (where needed) and that there is no problematic polypharmacy.

NICE, the American Heart Association (AHA), the American College of Cardiology (ACC) and The European Society of Cardiology (ESC) clinical guidelines recommend risk factor modification by optimisation of drug therapies for secondary prevention in patients who have suffered a myocardial infarction.

NICE (2009) estimates the level of non-adherence to medicines in patients with long-term conditions to be between 33 to 50%. Several studies show that there is a significant level of non-adherence to secondary prevention medicines by CHD patients. This was associated with a 10–40% relative increase in risk of cardiac hospitalisations and a 50–80% relative increase in mortality.

A recent observational study found that more than 25% of patients with pre-existing coronary heart disease who were re-admitted to hospital with an acute coronary syndrome (ACS) were on suboptimal secondary prevention drug therapies. A large proportion of those patients were also not achieving adequate cholesterol and blood pressure targets, which, in turn, might have been a major contributory factor for their re-presentation to hospital. Evidence shows that patients with high cholesterol who do not adhere to their medications have a 26% greater likelihood of a cardiovascular-related hospitalization compared to patients who adhere to their prescriptions.

Our “First Reported Adherence vs. Non-Adherence” study (soon to be submitted for publication) conducted by Khatib R. et al. showed that 44% of patients (N=500) in West Yorkshire who have CHD are not adherent to at least one secondary prevention medicines. The study identified several major modifiable barriers to adherence to secondary prevention medicines that can be addressed in clinic practice. We wanted to apply these findings into practice to improve adherence and reduce modifiable cardiovascular risk factors. Our research and audits showed that around 40-50% of our cardiovascular patients are not adhering to at least one of their long term medicines.

At 6 weeks post discharge, > 60% of our patients are not getting their secondary prevention medicines as recommended by NICE. Due to the size of our Trust, patients waited 88 days on average before being seen by a cardiologist post-discharge. Our services did not have an established post-MI patient tailored medicines optimisation provision. It was envisaged that addressing these gaps in service will improve patients’ experience, meeting NICE national targets for post-MI care, and reduce risk of readmissions and, potentially, mortality.

We secured research funding as part of a joint working agreement with AstraZeneca to roll out a proof of concept project to address the post-medicines optimisations issues identified by our previous research and audits in this area. We worked in collaboration between the cardiology and pharmacy department and established a Post-MI Medicines Optimisation MDT clinics. Those clinics were consultant cardiology pharmacist-led and ran in parallel with a consultant cardiologist and supported by a cardiology research nurse.

Based on our research in medicines adherence we developed a new tool which enables patients to share any barriers to adherence that they might have. We called it the My Experience of Taking Medicines Questionnaire (MYMEDS).

• All Leeds based MI patients were triaged to attend the new Post-MI Medicines Optimisation Service.
• Patients were sent the MYMEDS questionnaire to complete before attending clinic and bring with them to clinic.
• Patients who attended clinic, were triaged to be seen by the Consultant Cardiology Pharmacist, Consultant Cardiologist, or both depending on their needs.
• The consultation style was changed, we adopted a patient-centred approach and strived to meet the needs of the patients first.
• Patients shared with us the MYMEDS questionnaire, and the consultation focused on issues that they highlighted in the Questionnaire.
• Patients were provided with a full plan and a summary of the consultation including main action points. A summary was also shared with the GP and the cardiac rehabilitation team to ensure continuity of care.

Data was collected in clinic, after clinic, 3-6 months after clinic, and 8-12 months post MI to evaluate impact of the new service on patient experience, adherence, and other outcomes such as re-admission.

The project produced excellent results, and over 500 patients were seen in the clinic in the first year.

1) The patient experience has been improved significantly. Patients were very pleased with the new service and felt involved, their needs were fully met and their concerns were addressed.

2) The levels of medicines optimisation post MI were improved significantly. For example the optimisation of ACE inhibitors dosing was improved from 16% to 74% and Beta blocker dosing from 6% to 46% only after one visit. Multiple barriers to adherence were identified and addressed.

3) The levels of adherence to secondary prevention medicines as measured at 3- 6 months post attending clinic improved significantly.

4) The new service created capacity within the cardiology outpatient clinics leading to reducing the waiting time to be seen post discharge by over 50%.

5) The ACS readmission rate after introducing the service was reduced by around 50% compared to standard care before introducing the project.

6) Persistence on optimal secondary prevention medicines at 10-12 months post discharge was significantly improved compared to standard care (70% vs. 30% respectively).

7) The patients loved the MYMEDS questionnaire and found it very useful to help them to think about all medicines related issues in advance. This made the consultation more structured and relevant to patients.

Examples of patient comments:

• "I found the questionnaire helpful - in that it encouraged me to find out and understand more about my medications"

• "Friendly and approachable. The discussion regarding my medications was aimed at an appropriate level. I felt totally included in any decisions regarding my meds."

• "Took me through all my medication and listened to my concerns and then explained in detail the reasons for them. I came away completely reassured. "

• "I have never sorted and talked about my medicines in this way. Everything was discussed in length and all my questions were answered and covered fully. Well organised. Helpful staff. I didn't wait long and the Consultant Pharmacist explained everything thoroughly."

• "Every effort was made to give one confidence in the medicines, but just as important was the fact that one was told it was ok to report and discuss S/E".

Please refer to the impact sheet for more details. After presenting the findings, the service was commissioned by Leeds North CCG  and has become the new way we care for our post-MI patients to ensure that their medicines are optimised.

• Collaboration and multidisciplinary working is central to the delivery of medicines optimisation in practice.
• Patient centred care means that we need to listen more to patients and tailor our consultations to meet their needs.
• Data collection is important to show that your interventions work and to support any business case that you plan to submit.
• Ensure the outcomes you measure are relevant and important to your patients and to the healthcare system in its totality.
• When conducting research, always consider how it can be translated into practice to make it more relevant to patients and their needs as soon as possible.
• In line with the new Carter recommendations, pharmacists working alongside other healthcare professionals can deliver real medicines optimisation as NICE recommended. Currently we are developing a training programme to enable other cardiology pharmacist to run similar programme.