The Pharmacist's Role in Coronary Artery Bypass Graft
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TRANSITIONS OF CARE The Pharmacist’s Role in Coronary Artery Bypass Graft by Corey Marin, PharmD BACKGROUND According to the American Heart Association, one in three deaths each year is related to cardiovascular disease (CVD). CVD may lead patients into elective or non-elective surgeries to decrease mortality and improve quality of life. In 2017, the Centers for Medicare & Medicaid Services (CMS) will add the initial diagno- sis of coronary bypass artery graft (CABG) surgery to the Hospital Readmission Reduction Program (HRRP). CABG surgery is performed due to worsening coronary artery disease (CAD), where the buildup of plaque in the arteries has put the patient at an increased risk of myocardial ischemia and myocardial infarction. As the stenosis wors- ens, a patient’s risk continues to rise. Therefore, CABG is completed to reduce these risks and increase oxygenated blood flow to the heart muscle tissues. Reducing myocardial ischemia and myocardial infarction risk, relieving angina, and improving one’s ability to perform physical activity are benefits of CABG, if surgery is necessary. Though the types of CABG surgery may vary by institution or patient specifics, the medications during the preoperative, perioperative, and postoperative times differ little. This is where you, the community pharmacist, can help de- crease the chances of readmission following a CABG procedure and improve patient outcomes. HOW DID CMS GET TO THIS? In 2012, the Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE) created a CABG Measure Methodol- ogy Report for CMS. The document’s goal was to develop risk-adjusted CABG Editor’s Note: For information on references used in this article, contact Chris Linville at [email protected]. www.americaspharmacist.net 37 outcome measures that reflect the Medicare Payment per readmission at be funded by grants, by the hospi- quality of care patients receive when $8,136. Overall, preventing readmission tal, and partly by realized savings if undergoing CABG surgery for the of CABG patients could save Medicare the collaboration helps the hospital upcoming addition to HRRP. at least $151 million a year. reduce or avoid an HRRP penalty. Absent a formal partnership, having Data from Medicare Fee-for-Service THE PHARMACISTS’ ROLE the patient, family member, or care- (FFS) was used to show that readmis- Upon discharge following a CABG, giver bring the discharge summary sion rates following CABG surgery patients will have prescriptions for to the pharmacy is the first step in varied across hospitals. From January an antiplatelet therapy (aspirin or ensuring appropriate therapy. Often 2009 – September 2011, the median clopidogrel), a beta blocker, a nitrate, these discharge summaries will dis- readmission rate for all hospitals after a renin-angiotensin system antag- continue, hold, or add medications. CABG was 16.8 percent (range 11.2 onist, a lipid lowering agent (statin Without obtaining this information, percent - 22.2 percent). This is similar preferred), and other short-term med- the pharmacy may be unaware of to data published in a 30 day all cause ications. Whether these are old or any changes, which could result in readmission in New York state where new medications, patients will most suboptimal care. Knowing and dis- the median readmission rate was 16.5 likely be overwhelmed and confused cussing medication changes with the percent. Of the patients readmitted in with their changes. Pharmacists who patient is the first step in ensuring a New York, 87.3 percent were relat- want to partner with a cardiology decreased readmission risk. ed to the initial CABG surgery, 14.4 practice to reduce readmissions percent were related to complications could propose medication reconcil- ADHERENCE of CABG surgery, and these patients iation, bedside delivery of discharge The American College of Cardiology had an overall three-fold higher 30-day medications, and planned follow-up states that between 31-58 percent of mortality rate. calls to ask about side effects, taking all cardiovascular patients are non-ad- medications on time, and facilitating herent. This is a major gap in the care The costs of readmission can be detri- medication refills. In exchange, a for these patients because adherence mental to overall health care costs. In pharmacist might propose a de- is a simple way to improve outcomes. 2007, the Medicare Payment Advisory fined role in discharge planning, Types of non-adherence include not Committee (MedPAC) produced a receiving a copy of discharge orders, taking the medication, not taking report showing CABG to be the most receiving prescriptions for discharge the right medication, and taking the costly in potentially preventable re- medications, and compensation for medication incorrectly. As communi- admission cases following discharge, services. For now, as the business ty pharmacists, adherence is at the and second highest for average model evolves, compensation might heart of our competencies. Table 1: Associated Risk Factors for Readmission CABG, so patients will have to care for their chest and/or leg surgical Female wounds. To decrease readmissions, African American test studies created post-discharge Increased BMI (>30 kg/m2) care networks between hospitals Saphenous vein graft only and pharmacies to improve medica- One or more comorbidity tion reconciliation, patient education Renal failure following surgery about medication changes, patient Unplanned cardiac reoperation following surgery access to medications, and pa- tient follow-up with outpatient care Interactive Counseling Methods providers. Reports have shown that • What did your prescriber tell you the medication is for? collaboration between the two have • How did your prescriber tell you to take the medication? reduced hospital readmission rates. • What did your prescriber tell you to expect? The State Action on Avoidable Rehos- Adapted from the Indian Health Service Standards of Practice pitalization (STAAR) initiative reported data from 2010-2013 in which high- risk patients were identified as those A recent study from Oregon State MODIFIABLE RISK FACTORS taking 10 or more medications with University has shown that utilizing Many CVD patients will have a history at least one condition: heart failure, the Indian Health Service Model of smoking, elevated stress, poor pneumonia, acute renal failure, atrial for counseling directly improves a diet and exercise habits, uncon- fibrillation, cancer pain, dehydration, patient’s understanding and adher- trolled hypertension, and diabetes. urinary tract infection, or change in ence to his or her medication. The Implementation of active programs, mental status. It was determined that Indian Health Service method is an such as patient outreach, smoking 52 percent of patients had medica- interactive method that is based on cessation, and diabetes self-manage- tion-related issues because they were open-ended questions that refer to the ment education are a few examples unable to follow instructions. The name and purpose of the medication, of how pharmacies could reduce a most common issue was the patient’s its use and storage, and potential patient’s risk of complications. For inability to follow proper dosing in- side effects. These questions often example, an estimated 40 percent of structions. Screening for poor health begin with words such as: what, patients will develop depression after literacy or simple misunderstanding is why, how, or describe. (See sidebar.) CABG surgery. These patients would just one example of the ways a phar- They successfully create a dialogue normally go untreated until they were macist can bring improved patient between the pharmacist and patient readmitted to the hospital, but a pa- outcomes to post-discharge transi- by allowing the pharmacist to identify tient outreach program could identify tions of care. gaps in the patient’s understanding of this development and aid the patient the medication. before potential readmission. CONCLUSION The opportunity for community phar- Along with appropriate counseling, MAIN REASONS macies to intervene with patients after these patients are excellent candi- FOR READMISSION CABG surgery is feasible through a dates for medication synchronization. In Hannan et al., the top three causes variety of services. Using a pharma- This type of program allows a patient of readmission after CABG surgery cist’s pharmacotherapy knowledge to pick up all of their medications at were post-operative infections, and appropriate counseling methods, the same time each month. In this heart failure, and surgical compli- adherence can improve, which can way, patients can have an easier time cations. These readmissions may reduce the need for revascularization managing their medications without be furthered assessed by knowing later in life. Pharmacists can be instru- accidentally forgetting one. It is criti- a patient’s risk factors that increase mental in improving patient quality of cal to increase patient adherence and their overall risk of readmission. (See life after CABG surgery and decreas- outcomes along with saving health Table 1.) While these are all poten- ing the chances of readmission. ■ care system spending by reducing tially outside the realm of at-home the need for hospitalization. Counsel- treatment, there are ways to improve Corey Marin, PharmD, is a 2016 graduate ing and synchronization are just two outcomes. For example, preventing of the University of Iowa and was a winter methods to aid in improvement. infection is important following 2016 APPE rotation student at NCPA. www.americaspharmacist.net 39.