Abstract
Patients with atherosclerotic disease share a common set of modifiable risk factors, which are commonly untreated, undertreated, or managed with overlap by multiple disciplines, emphasizing the need for an integrated approach to their care. A key component of an integrated approach is defining the scope of each provider. 1 Clinical pharmacists are highly trained in disease state management and drug therapy. The purpose of this study was to describe the role of the clinical pharmacist in an integrated heart and vascular clinic.
This retrospective, single-center study was conducted at the Circulation and Vascular Clinic at The Ohio State University Wexner Medical Center. This innovative clinic used a multidisciplinary team including an interventional cardiologist, vascular surgeon, nurse practitioner, physician assistant, and registered nurses. The Circulation and Vascular Clinic pilot was held once weekly on Friday afternoons beginning in May 2016. A pharmacist joined the pilot in September 2016 and participated in new and established visits. The clinic pilot’s purpose was to offer comprehensive cardiovascular and vascular care to high risk patients in an inner-city community hospital with the goal of improving overall quality of care. We describe in this study the utilization and impact of the clinical pharmacist within the pilot.
This study included patients aged 18–89 years with atherosclerotic disease or at least three atherosclerotic risk factors, including hypertension, hyperlipidemia, diabetes, cigarette smoking, and male age ≥65 years or female age ≥70 years seen in the clinic over 4 months. Pharmacist interventions were categorized by reason and type. Reasons included untreated, undertreated, overtreatment, or monitoring of risk factor (i.e. order lipid panel) and non-adherence to treatment, and types included addition, deletion, change, or monitoring of therapy, patient education, and medication access. All recommendations were discussed with the providers before implementation. Aspirin and statin therapies were assessed for each patient as both agents are recommended for most patients included in this study based on national guidelines.2,3 To determine the impact of the pharmacist, atherosclerotic risk factor control and aspirin and statin use were reassessed at follow-up and compared to previous encounters.
Prior to each clinic, the pharmacist reviewed patients to determine atherosclerotic risk factor control. During the clinic, the pharmacist interviewed patients and interventions were discussed with the team. The pharmacist educated the patient on changes and documented the team’s assessment of the patient’s atherosclerotic risk factor control and interventions in the electronic medical record. On average, the pharmacist saw four of the six to eight patients seen by the team in each clinic.
Forty-two patients were included with a mean age of 66 years (standard deviation 10.6 years), with 61.9% male and 73.8% white. A total of 45% of patients had coronary artery disease and 42.9% had peripheral artery disease. Patients presented with multiple atherosclerotic risk factors, including hypertension (97.6%), hyperlipidemia (73.8%), diabetes (42.5%), and being current smokers (31.0%). At baseline, 76.2% of patients were taking a statin and 69.0% were taking aspirin.
The pharmacist intervened on 83.3% of patients (35/42). There were 76 total interventions, averaging 2.2 per patient. The primary reasons for intervention were untreated risk factor (35/76; 46.1%) and monitoring of risk factor (23/76; 30.3%). The most common untreated risk factors were cigarette smoking (17/35; 48.6%), no aspirin despite indication (8/35; 22.9%), and untreated hyperlipidemia (7/35; 20.0%).
Eighty-three percent (n=63/76) of interventions were accepted. The most common interventions were patient education, addition of therapy, and monitoring of therapy (Table 1). Smoking cessation counseling was the primary type of patient education and statin and aspirin were the most common additions of therapy. Eight patients were seen for additional visits during the study period, which allowed the pharmacist to follow-up on previous intervention. At the study end, overall statin use increased to 90.5% (n=38/42) and aspirin use increased to 83.3% (n=35/42).
Type of intervention performed by the clinical pharmacist and acceptance rates.
Denominator for the ‘Accepted’ column are the patients who had the intervention performed (n=76).
Pharmacists were frequently utilized in high risk patients of an integrated heart and vascular clinic for risk factor modification. Similar to our study, the REACH Registry found that guidelines for the management of atherosclerotic risk factors were infrequently followed with underutilization of evidence-based therapies like statins and aspirin. 4 Our study also found that pharmacist intervention contributed to improvements in the appropriate use of aspirin and statin therapy.
The pilot phase of the clinic contributed to a small sample size and limited follow-up. Medication adherence was not consistently assessed in each patient due to inconsistent utilization of a medication adherence questionnaire which was later reinforced at the end of the study. Lastly, many patients were managed by outside providers, which may have negatively impacted our ability to follow-up on interventions.
In conclusion, a clinical pharmacist in an integrated heart and vascular clinic improved the identification and management of atherosclerotic risk factors in a high risk patient population. The results of this study will help to solidify the pharmacist as a member of other heart and vascular clinics.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
