Initiation of Secondary Prevention Medications for Myocardial Infarction using Technology-Assisted Pharmacist Intervention

Anthony Kessels, Pharm.D., BCPS, Thomas Bailey, M.D., Laura Noirot, B.S., William C. Dunagan, M.D., Erin Rachmiel, Pharm.D., BCPS, Rina Shah, Pharm.D., BCPS,

Barnes-Jewish Hospital
St. Louis, Missouri

Purpose

Secondary prevention guidelines for the treatment of coronary artery disease have been well researched and established, including the use of aspirin, β-adrenergic blocking agents, angiotensin-converting enzyme inhibitors (ACE-I), and statins to decrease the risk of subsequent cardiac events and death. Despite well-documented evidence, an unacceptably low number of patients are discharged on these therapies in the United States. Studies have shown that in-hospital initiation of secondary prevention medications increases outpatient compliance and improves long-term outcomes. Recognizing this, a computerized system to alert pharmacists of the need to review the medication therapy of inpatients following an acute MI was designed and implemented to increase adherence with the secondary prevention guidelines.

Description of the Program

Data were initially gathered on the percentage of patients at Barnes-Jewish Hospital discharged on appropriate post-myocardial infarction (MI) medication therapy. At baseline, only 88% of patients were prescribed aspirin, 71% β-blockers, 60% ACE-Is, and 80% statins upon discharge. Additionally, only 67% of patients had a lipid panel drawn within 24 hours of admission. Based on the low percentage of patients discharged on optimal medications, we designed a program to improve compliance with secondary prevention guidelines by using a decision-support application with pharmacist intervention.

Between February 2000 and May 2001, we conducted a preliminary study to determine whether pharmacist intervention could increase the proportion of patients discharged on an optimal medication regimen in the post-MI period. We used a positive troponin (> 1.4 mg/dL) within 24 hours of admission to identify patients with acute MI. Study pharmacists then intervened on two medicine teams to ensure that eligible patients were initiated on appropriate post-MI medications. Two other medicine teams served as the control group. This study demonstrated substantial improvement in prescription rates of appropriate post-MI medications with pharmacist intervention.

After demonstrating better adherence to guidelines among patients in the intervention group, the program was expanded to all patients with acute MI with troponins greater than 1.4 mg/dL. In addition, inpatient pharmacists were held accountable for this intervention as part of their patient-care responsibilities. Major implementation steps included the following:

1. Establishing a real-time clinical process to identify all patients with positive troponins.
2. Performing lipid panels on all patients with elevated troponins.
3. Developing a decision support system to evaluate post-MI medications and valid contraindications.
4. Implementing an intranet website to alert pharmacists to patients’ demographic information, post-MI medication regimens, and other pertinent information.
5. Training pharmacy staff to communicate with physicians to ensure that patients are started on appropriate medications before discharge.

Experience with the Program

Average rates of discharge prescriptions are substantially greater than original baseline percentages and have met targets for all agents. Aspirin discharge prescription rates have improved to a mean of 98%, β-blockers 98%, ACE-I 94%, and statins 97%. In operation for over two years, the program has maintained the improvement in the percentage of patients discharged on an appropriate post-MI medication regimen.

Conclusion

A computerized system was successful in alerting pharmacists to inpatients with acute MI, thereby facilitating communication with physicians to ensure that appropriate post-MI medication therapy could be initiated before discharge.