Discussion
The present study showed the positive impact of a novel post-MI clinic, which provided access to a consultant cardiology pharmacist or a cardiologist or both, on a range of measures, including optimisation of secondary prevention medicines and patient adherence. It demonstrates that collaboration and multidisciplinary working are central to the delivery of effective medicines optimisation. However, although patients had access to both a consultant cardiology pharmacist and a cardiologist, as needed, the majority of patients (>95%) were seen only by the consultant cardiology pharmacist. Hence, this new service freed-up cardiology outpatient clinics and created more outpatient capacity. Importantly, patients were happy with the arrangement despite not being seen by the cardiologist; on the contrary, most were pleased with the pharmacist consultation and with the service in general as it adopted a patient-centred approach.
The mean time from discharge to clinic attendance was around 7 weeks (49.4 days), which was substantially lower than the mean waiting time to first outpatient cardiology review before the service began (88 days). One of the key early learnings of the project was the need to improve the outpatient booking system, and once that had been improved, patients were seen even more rapidly.
The model aligns with UK guidance from the National Institute for Health and Care Excellence (NICE), which recommends that structured medicines reviews should be considered for all patients with long-term conditions and/or taking multiple medicines.10 This guidance also notes that organisations should decide locally on the most appropriate healthcare professional to lead these reviews, within the context of an MDT, and that a pharmacist may be an appropriate choice.10 The recent Carter review of productivity and performance in English NHS acute hospitals proposed that local trusts should deploy more clinical pharmacists, including pharmacist prescribers, to drive value in medicines spending, including optimisation activities.11
From an international perspective, a pharmacist-led model of medicines optimisation may not be applicable in all countries, particularly those where non-physician prescribing is not possible or where the role of the clinical pharmacist is less developed. However, structured reviews led by a physician rather than a pharmacist can be undertaken post-MI in most developed healthcare systems, and this work demonstrates their potential value.
The model adopted in this study aligned with the principles of medicines optimisation and adherence defined by NICE.5 10 In particular, the MYMEDS questionnaire enabled patients to think about actual or potential issues that might affect their ability to take their medicines and to derive maximum benefit from them. Furthermore, the consultation embraced a patient-centred approach and focused on the concerns that they highlighted in the MYMEDS questionnaire. Patients were encouraged to come primed with all of their questions and felt that the clinic was particularly fulfilling because it addressed their needs. They also felt more involved. Overall, this approach brought to reality the concept of ‘shared decision-making’, which is frequently recommended3 5 10 but often difficult to deliver.
As a result, not only were secondary prevention medicines optimised but also substantial improvements in adherence were also achieved. This may have resulted from increased patient understanding of their medicines and the creation of specific action plans for overcoming barriers to adherence.
The association between improved adherence and improved long-term outcomes is well established.7 8 12 However, a recent Cochrane review of 182 trials of interventions designed to improve adherence to prescribed medications highlighted a lack of techniques with substantial impact on both adherence and outcomes.13 It is therefore encouraging that the present study was associated not only with an improvement in adherence but also improved outcomes, in the form of reduced hospital readmission rates at 30, 60 and 90 days postdischarge. Although the mean time between discharge and attending the medicines optimisation clinic was 49 days across the data set, 22% of patients were seen within 30 days.
We must acknowledge some important limitations of the present study, in particular its retrospective design and the lack of a comparator arm for most outcome measures. A prospective, randomised controlled trial would certainly be valuable. In addition, self-reported adherence has its limitations, particularly with respect to overestimation. Adherence behaviour changes over time, and hence it would be useful to remeasure over longer-term time points. Another limitation that should be acknowledged is that the findings only apply to patients who did not need any further non-pharmacological coronary interventions post discharge. Not all patients completed the questionnaire and those who did not tended to be younger. Finally, there was a statistical analysis limitation resulting from the design of the study. While more powerful statistics could have been performed on paired data, not all of data could be paired because patient anonymity was offered in some questionnaires to reduce the risk of social desirability. Despite this, suitable statistical analyses were applied.
However, overall, the current study demonstrates 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.