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Improving care and reducing variation of cardiovascular disease

Primary care pharmacist in Glasgow and member of the PDA Union Scotland and Northern Ireland Regional Committee, Iain Speirits has a split role working as a general practice pharmacist and in cardiology, supporting heart failure and post-MI patients. Here, Iain describes his role and the steps he takes to improve care and reduce variation in an area with the highest cardiovascular disease (CVD) mortality rate in the United Kingdom.

Tue 28th June 2022 The PDA

How I became involved in the care of people with CVD

I was fortunate to be interviewed for my inaugural NHS post by primary care lead pharmacist Dr Richard Lowrie. Richard has always held a keen interest in proving that pharmacist interventions can improve the quality of life for patients who are more socially disadvantaged and/or have significant long-term conditions. We began recruiting for the Heart Failure Optimal Outcomes from Pharmacy Study (HOOPS) in 2005 and after five years of follow-up, presented the results at the American Heart Association 2011 Scientific Sessions. This data was published in the European Heart Journal in February 2012. I was one of the pharmacists whose general practice was randomised to the intervention arm of this trial. My interest in caring for people with CVD has continued ever since.

What the current pharmacist care for CVD prevention looks like in Scotland

Pharmacist-led care for patients with CVD has evolved significantly in the last decade. On the back of HOOPS, we piloted and established a Health Board wide funded outpatient service for patients with left ventricular systolic dysfunction following myocardial infarction (MI). Patients are routinely referred to this pharmacist clinic, which has been shown to improve optimisation of pharmacological secondary prevention. This clinic accepts referrals from every hospital site in NHS Greater Glasgow and Clyde; the area with the highest mortality rate for CVD in the United Kingdom.

How my day-to-day role in CVD prevention differs by clinical setting

I divide my week into two segments, running the above clinic on a Monday and Tuesday and working in general practice from Wednesday to Friday. Our health centre serves an area of relatively high social deprivation. Prevention looks somewhat different in general practice, as in addition to reviewing patients with established CVD, there are large cohorts of patients at significantly increased risk of developing it. I actively recall patients with chronic kidney disease and/or hypertension and/or diabetes mellitus to ensure that they are well-managed and so reduce their risk of first MI.

The key learnings on my journey to date

It is essential to understand that people are unique, with differing levels of health understanding and biopsychosocial needs. All participants in a therapeutic consultation benefit most when treated as individuals. Never be afraid to ask questions; this is often the best way to elicit the required information and so inform decision-making. Reading the clinical history is vital, but so is engaging the patient. Respecting people’s choices is vital, even when you may disagree with them. The role of the health care professional is to present the information in an unbiased, readily understood manner and facilitate the decision-making process. The final decision lies with the patient.

The variations I see in clinical practice

Health literacy and treatment comprehension are affected significantly by levels of general education. Many of the patients I interact with struggle with literacy and numeracy and are often ashamed to say that they cannot read a medication label. Pride can also present a barrier to a positive treatment outcome. For example, patients with CVD are often limited in the extent to which they can undertake housework and activities of daily living. They may be reluctant to ask for help with these tasks, as they do not wish it to be known that their house is cluttered or unclean. This in itself has implications for their breathing and quality of life.

How I help to address these variations

I often signpost people to adult classes for arithmetic and English language, which are free at the point of access. I ask whether they have internet access at home and refer them to websites such as NHS Inform (Scotland’s national health information service) and the British Heart Foundation. If they do not, I provide a written information leaflet pertinent to the service or treatment in question. After seeking patient permission, I strive to involve family members, carers, friends, and neighbours in their care. In general, a maximum of two key messages can be successfully communicated at any given appointment; this process is assisted by the presence of others who know the patient well and have their best interests at heart.

How pharmacists in different sectors can adapt their services to improve inclusiveness in CVD prevention

The real solution to improving inclusiveness is time. Unfortunately, this is a commodity that community pharmacists have very little of. Patients often have multiple thoughts when they leave a clinic appointment, or a further question comes to mind on route to having their medication dispensed. I would like to see routine counselling of every patient presenting with a new medicine or dose change for the treatment of CVD disease. Continual re-enforcement is the key to improving understanding and so adherence to pharmacotherapy which reduces hospital admission and mortality. This enhanced time may be provided through wider use of robotics, pharmacy checking technicians, and/or a dual-pharmacist model, allowing one pharmacist to undertake a clinic.

How pharmacists can become more involved in the care of patients with CVD

We are continually seeking to upskill the next generation of pharmacists to work in cardiology clinics and wards. An increasing number of NHS-employed posts are being advertised to work in primary or secondary care settings. Although training is thorough, it is important that pharmacists have support and advice available from experienced colleagues when they need it. For pharmacists wishing to remain in a more general role, undertaking clinical skills training and attending specialist interest webinars will help to increase their knowledge and confidence. For example, chest auscultation, electrocardiogram interpretation, and phlebotomy, in addition to independent prescribing.

How you can better involve local colleagues in your work

Raising awareness of what you do with general practices, community nursing teams and allied healthcare professionals (AHPs) is vital. I have made the mistake of thinking that because our team has undertaken a robust clinical audit or implemented a novel workstream, local AHPs will be aware of it. My experience is that this is generally not the case. I have made a point of publicising the work that we do, both by telephoning or visiting local practices and pharmacies, in addition to journal publications. I have also presented our work at regional and national conferences and have found this to be a particularly effective way of networking.

How you can help push CVD higher up the local agenda

Although the overall burden of CVD is declining in the UK, it remains a significant cause of premature morbidity and mortality. Speaking with key stakeholders and decision-makers in your area can help to provide funding for future work in CVD prevention. Prescribing Leads are important people to involve, as they are heavily involved in the choice of key therapeutic targets for your local area.

By primary care pharmacist in Glasgow and member of the PDA Union Scotland and Northern Ireland Regional Committee, Iain Speirits

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