Q1 2019

16 GHP / Q1 2019 , Dr Rani Khatib, Consultant Pharmacist inCardiology and Cardiovascular Clinical Research at Leeds TeachingHospital, discusses howconsultant pharmacists can lead theway in ‘medicines optimisation’. The Consultant Pharmacist: A beacon for change Recently, I had a referral to my Advanced Cardiology Medicines Optimisation Clinic from one of our cardiologists to review a patient who had issues with their antihypertensives. After assessing his experience and thoughts about the medicines he was prescribed, it was clear that the patient was not satisfied with his current therapy – seven antihypertensives and no control of his blood pressure. The sad reality is that this can be common place. Pill burden for many patients is high. Many patients are on many medicines and their benefits and effectiveness are not routinely assessed. Medicines need to be optimised to meet the needs of patients, ensure that they are safe, and most importantly efficacious. In this case, we safely took the patient down from seven antihypertensive to three – needless to say, he was very pleased, and his blood pressure was well controlled by rationalising his antihypertensive therapy. A vital part of medicines optimisation is ensuring patients feel listened to and involved in the decision-making process about their conditions and medicines. This is only one snippet of what a consultant cardiology pharmacist does! 2018 saw the National Health Service celebrate its 70th anniversary, and over the last 70 years, while the core values have remained the same, the service that it provides and demographic that it treats has evolved dramatically. Over the last century, handwritten prescriptions in Latin have made way for computerised prescriptions dispensed by state-of-the-art machines. A quarter of the population live with a long-term medical condition and up to 50% of medicines prescribed for long- term conditions are not adhered to. The increasing problem of polypharmacy, multimorbidity and a medicated ageing population is driving greater scrutiny around clinical and cost-effectiveness, particularly in the context of widespread healthcare cuts. The modern-day patient requires clinical multidisciplinary teams to collaborate, now more than ever. We must drive best practice in complex care pathways to alleviate the health and economic burden that diseases place on already stretched healthcare systems. As part of my role as a Consultant Pharmacist, this is an area where there is a high expectation. We are responsible for leading the way in ‘medicines optimisation’ to help patients achieve the best outcomes with their treatments through patient and person- centred care. Medicines optimisation is guided by four principles which; recognise the patient experience, establish evidence-based treatment choices, ensure the safe use of medicines, and require medicines optimisation to be part of routine practice.1 Medicines optimisation drives innovation and ensures that healthcare systems benefit the patients they serve. An example of this can be seen in coronary heart disease, a condition which has, in the past, seen around 40% of patients not adhering to the life-saving therapies prescribed and the delivery of sub-optimal secondary prevention therapy in many cases. Somewhat surprisingly, these issues remained despite multiple national published guidance by National Institute of Healthcare Excellence (NICE), quality standards and technology appraisals aimed at addressing the burden of chronic heart disease. At six weeks post-discharge, we found that over 60% of our patients with myocardial infarction (MI) were not receiving their secondary prevention medicines as recommended by NICE guidelines. Through the application of the principles of medicines optimisation (and medicines adherence), my colleagues and I successfully re- engineered the post-MI pathway at our Trust. Based on previous research and audits carried out within our team, the cardiology and pharmacy departments collaborated to establish a post-MI Medicines Optimisation Clinic. Based on our research in medicines adherence, we were able to develop a tool which allows patients to communicate the barriers that can potentially prevent them from adhering to their medicines – the My Experience of Taking Medicines Questionnaire (MYMEDS). Within the first year, medicines optimisation post-MI were improved significantly with angiotensin converting enzyme (ACE) inhibitors dosing improving from 16% to 74% and beta blockers from 6% to 46%. The new service also created capacity within our cardiology outpatient clinics, which reduced the waiting time to be seen post-discharge by over 50%.3 The outcomes were not only well received by our patients and peers but has now been fully commissioned in Leeds after the first phase of the proof of concept was partially industry funded as part of a joint working agreement. Key to such innovation is reflection. Pausing to think about how a healthcare system should be fulfilling the needs of patients, encourages us as Consultant Pharmacists, with the support of multidisciplinary teams, to take stock and critically assess missed opportunities along the patient journey. The concept of missed opportunities is an important one, and it can often highlight room for improvement in places that a department may feel fairly confident in its performance. Another area that we explored recently with our cardiologists is the prevalence of anaemia among our patients who were admitted with heart failure. Along with a one of our leading heart failure nurses at my hospital in