Pharmacist-led intervention for older people with atrial fibrillation in long-term care (PIVOTALL study): a randomised pilot and feasibility study.

Atrial fibrillation Care homes Feasibility study Integrated care Medication optimisation Older people Pharmacists

Journal

BMC geriatrics
ISSN: 1471-2318
Titre abrégé: BMC Geriatr
Pays: England
ID NLM: 100968548

Informations de publication

Date de publication:
16 Jan 2024
Historique:
received: 21 06 2023
accepted: 28 11 2023
medline: 17 1 2024
pubmed: 17 1 2024
entrez: 16 1 2024
Statut: epublish

Résumé

Older care home residents are a vulnerable group of people with atrial fibrillation (AF) at high risk of adverse health events. The Atrial Fibrillation Better Care (ABC: Avoid stroke; Better symptom management; Cardiovascular and other comorbidity management) pathway is the gold-standard approach toward integrated AF care, and pharmacists are a potential resource with regards to its' implementation. The aim of this study was to determine the feasibility of pharmacist-led medicines optimisation in care home residents, based on the ABC pathway compared to usual care. Individually randomised, prospective pilot and feasibility study of older (aged ≥ 65 years) care home residents with AF (ISRCTN14747952); residents randomised to ABC pathway optimised care versus usual care. The primary outcome was a description of study feasibility (resident and care home recruitment and retention). Secondary outcomes included the number and type of pharmacist medication recommendations and general practitioner (GP) implementation. Twenty-one residents were recruited and 11 (mean age [standard deviation] 85.0 [6.5] years, 63.6% female) were randomised to receive pharmacist-led medicines optimisation. Only 3/11 residents were adherent to all three components of the ABC pathway. Adherence was higher to 'A' (9/11 residents) and 'B' (9/11 residents) components compared to 'C' (3/11 residents). Four ABC-specific medicines recommendations were made for three residents, and two were implemented by residents' GPs. Overall ABC adherence rates did not change after pharmacist medication review, but adherence to 'A' increased (from 9/11 to 10/11 residents). Other ABC recommendations were inappropriate given residents' co-morbidities and risk of medication-related adverse effects. The ABC pathway as a framework was feasible to implement for pharmacist medication review, but most residents' medications were already optimised. Low rates of adherence to guideline-recommended therapy were a result of active decisions not to treat after assessment of the net risk-benefit.

Sections du résumé

BACKGROUND BACKGROUND
Older care home residents are a vulnerable group of people with atrial fibrillation (AF) at high risk of adverse health events. The Atrial Fibrillation Better Care (ABC: Avoid stroke; Better symptom management; Cardiovascular and other comorbidity management) pathway is the gold-standard approach toward integrated AF care, and pharmacists are a potential resource with regards to its' implementation. The aim of this study was to determine the feasibility of pharmacist-led medicines optimisation in care home residents, based on the ABC pathway compared to usual care.
METHODS METHODS
Individually randomised, prospective pilot and feasibility study of older (aged ≥ 65 years) care home residents with AF (ISRCTN14747952); residents randomised to ABC pathway optimised care versus usual care. The primary outcome was a description of study feasibility (resident and care home recruitment and retention). Secondary outcomes included the number and type of pharmacist medication recommendations and general practitioner (GP) implementation.
RESULTS RESULTS
Twenty-one residents were recruited and 11 (mean age [standard deviation] 85.0 [6.5] years, 63.6% female) were randomised to receive pharmacist-led medicines optimisation. Only 3/11 residents were adherent to all three components of the ABC pathway. Adherence was higher to 'A' (9/11 residents) and 'B' (9/11 residents) components compared to 'C' (3/11 residents). Four ABC-specific medicines recommendations were made for three residents, and two were implemented by residents' GPs. Overall ABC adherence rates did not change after pharmacist medication review, but adherence to 'A' increased (from 9/11 to 10/11 residents). Other ABC recommendations were inappropriate given residents' co-morbidities and risk of medication-related adverse effects.
CONCLUSIONS CONCLUSIONS
The ABC pathway as a framework was feasible to implement for pharmacist medication review, but most residents' medications were already optimised. Low rates of adherence to guideline-recommended therapy were a result of active decisions not to treat after assessment of the net risk-benefit.

Identifiants

pubmed: 38229013
doi: 10.1186/s12877-023-04527-4
pii: 10.1186/s12877-023-04527-4
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

64

Informations de copyright

© 2024. The Author(s).

Références

World Health Organization. European Health Information Gateway. Number of nursing and elderly home beds. Available from: https://gateway.euro.who.int/en/indicators/hfa_491-5101-number-of-nursing-and-elderly-home-beds/ [cited 1 Jan 2023].
World Health Organization. Partnering with the EU to strengthen long-term care systems. Available from: https://www.who.int/europe/activities/partnering-with-the-eu-to-strengthen-long-term-care-systems [cited 13 Nov 2023].
Office for National Statistics. Care homes and estimating the self-funding population, England: 2021 to 2022. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/socialcare/articles/carehomesandestimatingtheselffundingpopulationengland/2021to2022 [cited 08 Sept 2022].
Benjamin Emelia J, Muntner P, Alonso A, BittencourtMarcio S, Callaway Clifton W, Carson April P, et al. Heart disease and stroke statistics—2019 Update: a report from the American Heart Association. Circulation. 2019;139(10):e56–528.
pubmed: 30700139
Heeringa J, van der Kuip DAM, Hofman A, Kors JA, van Herpen G, Stricker BHC, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J. 2006;27(8):949–53.
doi: 10.1093/eurheartj/ehi825 pubmed: 16527828
Ritchie LA, Harrison SL, Penson PE, Akbari A, Torabi F, Hollinghurst J, et al. Prevalence and outcomes of atrial fibrillation in older people living in care homes in Wales: a routine data linkage study 2003–2018. Age Ageing. 2022;51(12):afac252.
Bahri O, Roca F, Lechani T, Druesne L, Jouanny P, Serot J-M, et al. 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):71–6.
doi: 10.1111/jgs.13200 pubmed: 25597559
Lip GYH. The ABC pathway: an integrated approach to improve AF management. Nat Rev Cardiol. 2017;14:627.
doi: 10.1038/nrcardio.2017.153 pubmed: 28960189
Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS): the task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2020;42(5):373–498.
doi: 10.1093/eurheartj/ehaa612
Chao TF, Joung B, Takahashi Y, Lim TW, Choi EK, Chan YH, et al. 2021 Focused update consensus guidelines of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation: executive summary. Thromb Haemost. 2021;122(01):020–47.
Yang P-S, Sung J-H, Jang E, Yu HT, Kim T-H, Lip GYH, et al. Application of the simple atrial fibrillation better care pathway for integrated care management in frail patients with atrial fibrillation: a nationwide cohort study. J Arrhythm. 2020;36(4):668–77.
doi: 10.1002/joa3.12364 pubmed: 32782638 pmcid: 7411200
Proietti M, Romiti Giulio F, Olshansky B, Lane Deirdre A, Lip Gregory YH. Comprehensive management with the ABC (Atrial Fibrillation Better Care) pathway in clinically complex patients with atrial fibrillation: a post Hoc ancillary analysis from the AFFIRM trial. J Am Heart Assoc. 2020;9(10):e014932.
doi: 10.1161/JAHA.119.014932 pubmed: 32370588 pmcid: 7660878
Kotalczyk A, Guo Y, Stefil M, Wang Y, Lip GYH, null n. Effects of the atrial fibrillation better care pathway on outcomes among clinically complex Chinese patients with atrial fibrillation with multimorbidity and polypharmacy: a peport from the ChiOTEAF registry. J Am Heart Assoc. 2022;11(7):e024319.
NHS England. Care home pharmacists to help cut overmedication and unnecessary hospital stays for frail older patients. 2018. Available from: https://www.england.nhs.uk/2018/03/care-home-pharmacists-to-help-cut-over-medication-and-unnecessary-hospital-stays-for-frail-older-patients/ [cited 10 Jul 2022].
NHS England. Network contract directed enhanced service. Structured medication reviews and medicines optimisation: guidance. 2020. Available from: https://www.england.nhs.uk/wp-content/uploads/2020/09/SMR-Spec-Guidance-2020-21-FINAL-.pdf [cited 10 Jul 2022].
Ritchie LA, Penson PE, Akpan A, Lip GYH, Lane DA. Integrated care for atrial fibrillation management: the role of the pharmacist. Am J Med. 2022;135(12):1410–26.
doi: 10.1016/j.amjmed.2022.07.014 pubmed: 36002045
Eldridge S, Lancaster G, Campbell M, Thabane L, Hopewell S, Coleman C, et al. Defining feasibility and pilot studies in preparation for randomised controlled trials: development of a conceptual framework. PLoS One. 2016;11:e0150205.
doi: 10.1371/journal.pone.0150205 pubmed: 26978655 pmcid: 4792418
Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, et al. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. Pilot Feasibility Stud. 2016;2:64.
doi: 10.1186/s40814-016-0105-8 pubmed: 27965879 pmcid: 5154046
ISRCTN Registry. ISRCTN14747952: Pharmacist implementation of a treatment pathway for atrial fibrillation in care home residents. Available from: https://doi.org/10.1186/ISRCTN14747952 [cited 22 Aug 2021].
Billingham SA, Whitehead AL, Julious SA. An audit of sample sizes for pilot and feasibility trials being undertaken in the United Kingdom registered in the United Kingdom Clinical Research Network database. BMC Med Res Methodol. 2013;13:104.
doi: 10.1186/1471-2288-13-104 pubmed: 23961782 pmcid: 3765378
Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ, Lip GYH, et al. 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):263–72.
doi: 10.1378/chest.09-1584 pubmed: 19762550
Wynn GJ, Todd DM, Webber M, Bonnett L, McShane J, Kirchhof P, et al. The European heart rhythm association symptom classification for atrial fibrillation: validation and improvement through a simple modification. Europace. 2014;16(7):965–72.
doi: 10.1093/europace/eut395 pubmed: 24534264 pmcid: 4070972
EuroQol Group. EuroQol--a new facility for the measurement of health-related quality of life. Health Policy (Amsterdam, Netherlands). 1990;16(3):199-208
Brooks R. EuroQol: the current state of play. Health Policy (Amsterdam, Netherlands). 1996;37(1):53–72.
doi: 10.1016/0168-8510(96)00822-6 pubmed: 10158943
Spertus J, Dorian P, Bubien R, Lewis S, Godejohn D, Reynolds MR, et al. Development and validation of the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) Questionnaire in patients with atrial fibrillation. Circ Arrhythm Electrophysiol. 2011;4(1):15–25.
doi: 10.1161/CIRCEP.110.958033 pubmed: 21160035
Fabricio-Wehbe SC, Schiaveto FV, Vendrusculo TR, Haas VJ, Dantas RA, Rodrigues RA. Cross-cultural adaptation and validity of the “Edmonton Frail Scale - EFS” in a Brazilian elderly sample. Rev Lat Am Enfermagem. 2009;17(6):1043–9.
doi: 10.1590/S0104-11692009000600018 pubmed: 20126949
Fabrício-Wehbe S, Rosset I, Haas V, Diniz M, Spadoti D, Partezani-Rodrigues R. Reproducibility of the Brazilian version of the Edmonton Frail Scale for elderly living in the community. Rev Lat Am Enfermagem. 2013;21(6):1330–6.
doi: 10.1590/0104-1169.2933.2371 pubmed: 24271320
Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton frail scale. Age Ageing. 2006;35(5):526–9.
doi: 10.1093/ageing/afl041 pubmed: 16757522 pmcid: 5955195
Ramirez Ramirez JU, Cadena Sanabria MO, Ochoa ME. Edmonton frail scale in Colombian older people. Comparison with the fried criteria. Rev Esp Geriatr Gerontol. 2017;52(6):322–5.
Rolfson DB. Edmonton Frail Scale. 2020. Available from: https://edmontonfrailscale.org/frailty-covid-19 [cited 11 Sep 2020].
Katzman R, Brown T, Fuld P, Peck A, Schechter R, Schimmel H. Validation of a short orientation-memory-concentration test of cognitive impairment. Am J Psychiatry. 1983;140(6):734–9.
doi: 10.1176/ajp.140.6.734 pubmed: 6846631
Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;138(5):1093–100.
Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–95.
Clegg A, Bates C, Young J, Ryan R, Nichols L, Ann Teale E, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing. 2016;45(3):353–60.
Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61–5.
pubmed: 14258950
Schulman S, Kearon C. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost. 2005;3(4):692–4.
doi: 10.1111/j.1538-7836.2005.01204.x pubmed: 15842354
Maidment ID, Damery S, Campbell N, Seare N, Fox C, Iliffe S, et al. Medication review plus person-centred care: a feasibility study of a pharmacy-health psychology dual intervention to improve care for people living with dementia. BMC Psychiatry. 2018;18(1):340.
doi: 10.1186/s12888-018-1907-4 pubmed: 30340480 pmcid: 6194710
Nishtala PS, McLachlan AJ, Bell JS, Chen TF. A retrospective study of drug-related problems in Australian aged care homes: medication reviews involving pharmacists and general practitioners. J Eval Clin Pract. 2011;17(1):97–103.
doi: 10.1111/j.1365-2753.2010.01374.x pubmed: 20825538
Garattini L, Padula A. Hospital Pharmacists in Europe: between warehouse and prescription pad? Pharmacoecon Open. 2018;2(3):221–4.
doi: 10.1007/s41669-018-0069-0 pubmed: 29396660 pmcid: 6103922
Duncan P, Ridd MJ, McCahon D, Guthrie B, Cabral C. Barriers and enablers to collaborative working between GPs and pharmacists: a qualitative interview study. Br J Gen Pract. 2020;70(692): e155.
doi: 10.3399/bjgp20X708197 pubmed: 32041767 pmcid: 7015165
Ritchie LA, Gordon AL, Penson PE, Lane DA, Akpan A. Stop and go: barriers and facilitators to care home research. J Frailty Aging. 2023;12(1):63–6.
pubmed: 36629086
Ellwood A, Airlie J, Cicero R, Cundill B, Ellard DR, Farrin A, et al. Recruiting care homes to a randomised controlled trial. Trials. 2018;19(1):535.
doi: 10.1186/s13063-018-2915-x pubmed: 30285850 pmcid: 6169108
Lee SWH, Mak VSL, Tang YW. Pharmacist services in nursing homes: a systematic review and meta-analysis. Br J Clin Pharmacol. 2019;85(12):2668–88.
doi: 10.1111/bcp.14101 pubmed: 31465121 pmcid: 6955407
Ulfvarson J, Adami J, Ullman B, Wredling R, Reilly M, von Bahr C. Randomized controlled intervention in cardiovascular drug treatment in nursing homes. Pharmacoepidemiol Drug Saf. 2003;12(7):589–93.
doi: 10.1002/pds.855 pubmed: 14558182
Verrue C, Mehuys E, Boussery K, Adriaens E, Remon JP, Petrovic M. A pharmacist-conducted medication review in nursing home residents: impact on the appropriateness of prescribing. Acta Clin Belg. 2012;67(6):423–9.
pubmed: 23340148
Gordon AL, Franklin M, Bradshaw L, Logan P, Elliott R, Gladman JR. Health status of UK care home residents: a cohort study. Age Ageing. 2014;43(1):97–103.
doi: 10.1093/ageing/aft077 pubmed: 23864424
The International Consortium for Health Outcomes Measurement (ICHOM). Patient-centered outcome measures - older person. Available from: https://connect.ichom.org/patient-centered-outcome-measures/older-person/ [cited 27 Jul 2022].

Auteurs

Leona A Ritchie (LA)

Liverpool Centre for Cardiovascular Science, William Henry Duncan Building, University of Liverpool, Liverpool, L7 8TX, UK. leona.ritchie@liverpool.ac.uk.
Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L7 8TX, UK. leona.ritchie@liverpool.ac.uk.
Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, L3 3AF, UK. leona.ritchie@liverpool.ac.uk.

Peter E Penson (PE)

Liverpool Centre for Cardiovascular Science, William Henry Duncan Building, University of Liverpool, Liverpool, L7 8TX, UK.
Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, L3 3AF, UK.

Asangaedem Akpan (A)

Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L7 8TX, UK.
Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, UK.

Gregory Y H Lip (GYH)

Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK.
Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.

Deirdre A Lane (DA)

Liverpool Centre for Cardiovascular Science, William Henry Duncan Building, University of Liverpool, Liverpool, L7 8TX, UK.
Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L7 8TX, UK.
Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.

Classifications MeSH