Clinical pharmacist implementation of a medication assessment tool for long-term management of atrial fibrillation in older persons
Main Article Content
Keywords
Atrial Fibrillation, Disease Management, Drug Utilization Review, Medication Therapy Management, Inappropriate Prescribing, Pharmaceutical Services, Pharmacists, Aged, Clinical Audit, Malta
Abstract
Background: Optimisation of drug therapy is important in the older population and may be facilitated by medication assessment tools (MATs).
Objective: The purpose of the study was to evaluate whether appropriateness of drug therapy and clinical pharmacist intervention documentation improved following implementation of a previously developed MAT for the long-term management of atrial fibrillation (MAT-AF).
Methods: Adherence to MAT-AF review criteria and clinical pharmacist intervention documentation was assessed by the researcher pre-MAT implementation in 150 patients aged ≥60 years admitted to a rehabilitation hospital with a diagnosis of atrial fibrillation. MAT-AF was introduced as a clinical tool in the hospital for identification of pharmaceutical care issues in atrial fibrillation patients. Adherence to MAT-AF and pharmacist intervention documentation were assessed by the researcher post-MAT implementation for a further 150 patients with the same inclusion criteria. Logistic regression analysis and measurement of odds ratio was used to identify differences in adherence to MAT-AF pre- and post-MAT implementation. The differences between two population proportions z-test was used to compare pharmacist intervention documentation pre- and post-MAT implementation.
Results: Adherence to MAT-AF criteria increased from 70.9% pre-implementation to 89.6% post-implementation. MAT-AF implementation resulted in a significant improvement in prescription of anticoagulant therapy (OR 4.07, p<0.001) and monitoring of laboratory parameters for digoxin (OR 10.40, p<0.001). Clinical pharmacist intervention documentation improved significantly post-implementation of MAT-AF (z-score 20.249, p<0.001).
Conclusions: Implementation of MAT-AF within an interdisciplinary health care team significantly improved the appropriateness of drug therapy and pharmacist intervention documentation in older patients with atrial fibrillation.
References
2. Castelino RL, Bajorek BV, Chen TF. Targeting suboptimal prescribing in the elderly: A review of the impact of pharmacy services. Ann Pharmacother. 2009;43(6):1096-1106. https://dx.doi.org/10.1345/aph.1L700
3. Kaur S, Mitchell G, Vitetta L, Roberts MS. Interventions that can reduce inappropriate prescribing in the elderly. Drugs Aging. 2009;26(12):1013-1028. https://dx.doi.org/10.2165/11318890-000000000-00000
4. Spinewine A, Fialova D, Byrne S. The role of the pharmacist in optimizing pharmacotherapy in older people. Drugs Aging. 2012;29(6):495-510. https://dx.doi.org/10.2165/11631720-000000000-00000
5. Cooper JA, Cadogan CA, Patterson SM, Kerse N, Bradley MC, Ryan C, Hughes CM. Interventions to improve the appropriate use of polypharmacy in older people: A Cochrane systematic review. BMJ Open. 2015;5(12):e009235. https://dx.doi.org/10.1136/bmjopen-2015-009235
6. American Society of Health-System Pharmacists (ASHP). ASHP guidelines on documenting pharmaceutical care in patient medical records. Am J Health-Syst Pharm. 2003;60(7):705-707. https://dx.doi.org/10.1093/ajhp/60.7.705
7. Royal Pharmaceutical Society. Guidance on recording of interventions. Pharm J. 2006;276:517-518.
8. Page RL, Linnebur SA, Bryant LL, Ruscin JM. Inappropriate prescribing in the hospitalized elderly patient: defining the problem, evaluation tools, and possible solutions. Clin Interv Aging. 2010;5:75-87. https://dx.doi.org/10.2147/CIA.S9564
9. Gauci M, Wirth F, Camilleri L, Azzopardi LM, Serracino-Inglott A. Assessing appropriateness of drug therapy in older persons: Development and application of a medication assessment tool for long-term management of atrial fibrillation. Pharm Pract (Granada). 2017;15(4):1021-1025. https://dx.doi.org/10.18549/pharmpract.2017.04.1021
10. January CT, Wann LS, Alpert JS, Calkins H, Cleveland JC, Cigarroa JE, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW. AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014;130(23):2071-2104. https://dx.doi.org/10.1161/cir.0000000000000041
11. National Institute for Health and Care Excellence (NICE). Atrial fibrillation: The management of atrial fibrillation. Clinical guideline 180. UK: NICE; 2014.
12. Macle L, Cairns J, Leblanc K, Tsang T, Skanes A, Cox JL, Healey JS, Bell A, Pilote L, Andrade JG, Mitchell LB, Atzema C, Gladstone D, Sharma M, Verma S, Connolly S, Dorian P, Parkash R, Talajic M, Nattel S, Verma A. 2016 Focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation. Can J Cardiol. 2016;30(10):1114-1130. https://dx.doi.org/10.1016/j.cjca.2016.07.591
13. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC guidelines for the management of atrial fibrillation: The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(38):2893-2962. https://dx.doi.org/10.1093/eurheartj/ehw210
14. Ziff OJ, Camm AJ. Individualized approaches to thromboprophylaxis in atrial fibrillation. Am Heart J. 2016;173:143-158. https://dx.doi.org/10.1016/j.ahj.2015.10.021
15. Electronic Medicines Compendium (eMC). Summary of product characteristics of digoxin 0.0625mg tablets. UK: eMC, January 2018. https://www.medicines.org.uk/emc/product/5464 (accessed Jul 5, 2018).
16. Electronic Medicines Compendium (eMC). Summary of product characteristics of amiodarone 200mg tablets. UK: eMC; May 2017. https://www.medicines.org.uk/emc/product/6018 (accessed Jul 5, 2018).
17. Kirchhof P, Curtis AB, Skanes AC, Gillis AM, Wann LS, Camm AJ. Atrial fibrillation guidelines across the Atlantic: A comparison of the current recommendations of the European Society of Cardiology/European Heart Rhythm Association/European Association of Cardiothoracic Surgeons, the American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society, and the Canadian Cardiovascular Society. Eur Heart J. 2013;34(20):1471-1474. https://dx.doi.org/10.1093/eurheartj/ehs446
18. Al-Khatib SM, Allen LaPointe NM, Chatterjee R, Crowley MJ, Dupre ME, Kong DF, Lopes RD, Povsic TJ, Raju SS, Shah B, Kosinski AS, McBroom AJ, Sanders GD. Rate- and rhythm-control therapies in patients with atrial fibrillation: A systematic review. Ann Intern Med. 2014;160(11):760-773. https://dx.doi.org/10.7326/m13-1467
19. Mamo M, Wirth F, Azzopardi LM, Serracino-Inglott A. Standardising pharmacist patient-profiling activities in a rehabilitation hospital in Malta. Eur J Hosp Pharm. 2014;21(1):49-53. https://dx.doi.org/10.1136/ejhpharm-2013-000351
20. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: The Euro Heart Survey on atrial fibrillation. Chest. 2010;137(2):263-272. https://dx.doi.org/10.1378/chest.09-1584
21. Lefebre MD, St-Onge M, Glazer-Cavanagh M, Bell L, Nam Kha Nguyen J, Viet-Quoc Nguyen P, Tannenbaum C. The effect of bleeding risk and frailty status on anticoagulation patterns in octogenarians with atrial fibrillation: The FRAIL-AF study. Can J Cardiol. 2016;32(2):169-176. https://dx.doi.org/10.1016/j.cjca.2015.05.012
22. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess one-year risk of major bleeding in atrial fibrillation patients: The Euro Heart Survey. Chest. 2010;138(5):93-100. https://dx.doi.org/10.1378/chest.10-0134
23. Suarez Fernandez CS, Formiga F, Camafort M, Cepeda Rodrigo JM, Diez-Manglano J, Pose Reino A, Tiberio G, Mostaza JM. Antithrombotic treatment in elderly patients with atrial fibrillation: A practical approach. BMC Cardiovascular Disorders. 2015;15:143. https://dx.doi.org/10.1186/s12872-015-0137-7
24. Mant J, Hobbs FD, Fletcher K, Roalfe A, Fitzmaurice D, Lip GY, Murray E. Warfarin vs. aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): A randomised controlled trial. Lancet. 2007;370(9586):493-503. https://dx.doi.org/10.1016/S0140-6736(07)61233-1
25. Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, Camm AJ, Weitz JI, Lewis BS, Parkhomenko A, Yamashita T, Antman EM. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: A meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962. https://dx.doi.org/10.1016/S0140-6736(13)62343-0
26. Graham DJ, Reichman ME, Wernecke M, Zhang R, Southworth MR, Levenson M, Sheu TC, Mott K, Goulding MR, Houstoun M, MaCurdy TE, Worrall C, Kelman JA. Cardiovascular, bleeding, and mortality risks in elderly medicare patients treated with dabigatran or warfarin for nonvalvular atrial fibrillation. Circulation. 2015;131(2):157-164. https://dx.doi.org/10.1161/circulationaha.114.012061
27. Pugh D, Pugh J, Mead GE. Attitudes of physicians regarding anticoagulation for atrial fibrillation: A systematic review. Age Ageing. 2011;40(6):675-683. https://dx.doi.org/10.1093/ageing/afr097
28. Sellers MB, Newby LK. Atrial fibrillation, anticoagulation, fall risk, and outcomes in elderly patients. Am Heart J. 2011;161(2):241-246. https://dx.doi.org/10.1016/j.ahj.2010.11.002
29. Banerjee A, Clementy N, Haguenoer K, Fauchier L, Lip GY. Prior history of falls and risk of outcomes in atrial fibrillation: The Loire Valley Atrial Fibrillation Project. Am J Med. 2014;127(10):972-978. https://dx.doi.org/10.1016/j.amjmed.2014.05.035
30. Bahri O, Roca F, Lechani T, Druesne L, Jouanny P, Serot JM, Boulanger E, Puisieux F, Chassagne P. Underuse of oral anticoagulation for individuals with atrial fibrillation in a nursing home setting in France: Comparisons of resident characteristics and physician attitude. J Am Geriatr Soc. 2015;63(1):71-76. https://dx.doi.org/10.1111/jgs.13200
31. Man-Son-Hing M, Nichol G, Lau A, Laupacis A. Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med. 1999;159(7):677-685. https://dx.doi.org/10.1001/archinte.159.7.677
32. Donze J, Clair C, Hug B, Rodondi N, Waeber G, Cornuz J, Aujesky D. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012;125(8):773-778. https://dx.doi.org/10.1016/j.amjmed.2012.01.033